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Uptake of first two doses of human papillomavirus vaccine by adolescent schoolgirls in Manchester: prospective cohort study

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39541.534109.BE (Published 08 May 2008) Cite this as: BMJ 2008;336:1056

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HPV vaccination coverage rate: a successful example of public health governance for a prevention strategy

 

As estimated in the feasibility study by Brabin et[1], an uptake of 68.5% for the second dose of a Human Papillomavirus (HPV) vaccine is definitively a relevant projection in a public health perspective. The goal of any public healthcare system consists of a complex combination of objectives, not all of which are always clearly and unequivocally assessable[2,3]. Indeed, governmental procedures suggest that priority setting in the allocation of funds by the Italian National Health Service through largely formal and structured processes must be consistent with specific Regional healthcare requirements which are autonomously measured and prioritized.

 

In randomized controlled trials, preventive vaccination against HPV demonstrated to be a remarkably powerful tool to avert HPV-induced outcomes such as abnormal pap smears, colposcopies, low and high-grade precancerous cervical lesions, cancer in situ, invasive cervical cancers, vulvar dysplastic lesions, vaginal dysplastic lesions, and genital warts[4-6]. However, as also reported in the guidance for the introduction of HPV vaccines in EU countries by the European Centre for Disease Prevention and Control, the penetration of the vaccine within the target population and the proportion of the target population that received all three doses are important parameters to predict and assess the impact of HPV vaccination[7].

 

In September 2007 the Region of Basilicata, located in southern Italy, effectively started an anti-HPV vaccination programme with the quadrivalent vaccine. Compared with other Italian Regions, Basilicata was the only Region that designed and implemented a HPV vaccination campaign with a multi-cohort strategy. The vaccination campaign is currently focused on four cohorts of girls aged 11, 14, 17 and 24 years. The selected vaccination strategy has led the Basilicata Region to gain an acknowledged leadership in the field of prevention and vaccination across Italy which depends on two main factors. Firstly, the achievement of a higher than expected vaccination coverage rate in a 9-month time span corresponding to a weighted mean of 65%±10% and 73%±12% for 4 and 3 cohorts respectively (excluding twenty-four year olds who showed a lower completion rate of the 3 doses vaccination schedule during the time period) (table I) and also because a relatively high percentage of the National Healthcare Fund has been channelled for prevention and vaccination in this Region (6% of the total National Healthcare Fund compared with a mean of approximately 1% among the other Regions[8]). As expected, these results would never have been accomplished without the strong commitment of political decision makers who performed a value-based political and economical evaluation. In such circumstances, a rigorous cooperative framework that allows stakeholders to discuss the values to be used in setting priorities is mandatory. These successful preliminary results from the anti-HPV vaccination program in Basilicata also suggest that a truly comprehensive process of healthcare governance requires both public input (to understand individual and societal needs) and economic affordability (to support the rationale for decisions)[9].

 

The implementation of a multi-cohort vaccination strategy in our Region should provide clinical and economic results 8-10 years earlier than would be expected with a single cohort vaccination strategy. This can be deemed as good evidence of an optimal allocation of economic resources in public health.    

 

Table I - Parameters of anti-HPV vaccination coverage rate in the Basilicata Region

Cohorts

LHA* 1

LHA 2

LHA 3

LHA 4

LHA 5

Total

4 cohorts (12-15-18-25 yrs old)

 

 

 

 

 

 

Vaccinated

1,568

2,891

1,066

1,356

1,252

8,133

Eligible

2,118

4,413

1,603

2,750

1,769

12,653

Rate (%)

74.0

65.5

66.5

49.3

70.8

64.3

3 cohort (12-15-18 yrs old)

 

 

 

 

 

 

Vaccinated

1,329

2,327

881

1,036

1,015

6,588

Eligible

1,590

3,073

1,134

2,000

1,300

9,097

Rate (%)

83.6

75.7

77.7

51.8

78.1

72.4

*LHA = Local Health Authority

References

1.      Brabin L, Roberts SA, Stretch R, Baxter D, Chambers G, Kitchener H, and McCann R. Uptake of first two doses of human papillomavirus vaccine by adolescent schoolgirls in Manchester: prospective cohort study. BMJ 2008; 336: 1056-1058

2.      Holm S. Goodbye to the simple solutions: the second phase of priority setting in health care. BMJ 1998; 317: 1000-1007

3.      Sassi F. Setting priorities for the evaluation of health interventions: when theory does not meet practice. Health Policy 2003; 63: 141-154

4.      The FUTURE I Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent Anogenital Diseases The New England Journal of Medicine 2007;356:1928-1943

5.      The FUTURE II Study Group. Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. The Lancet 2007; Vol. 369: 1861-1868

6.      Paavonen J, Jenkins D, Bosch FX, et al. Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial. Lancet 2007; 369: 2161-2670

7.      Guidance for the introduction of HPV vaccines in EU countries. Guidance Report | Stockholm, January 2008.  Available at: http://ecdc.europa.eu/pdf/HPV_report.pdf

8.      Mennini FS, Francia L, Gitto L. CEIS Health Report 2007. Available at:  http://www.ceistorvergata.it/ricerca/areericerca/Publications/publications_health.htm Accessed September 2008

9.      Fleurence RL, and Torgerson DJ. Setting Priorities for Research. Health Policy 2004; 69: 1-10

Competing interests: None declared

Competing interests: No competing interests

12 November 2008
Giuseppe Montagano
MD, Hygienist, Department of Public Health of the Region Basilicata
Gabriella Cauzzillo, MD
Department of Health, Safety and Social Solidarity. Via V. Verrastro, 8 - 85100 Potenza, Italy