Australia has a tradition going back at least 50 years, of publicly-funded, school-based vaccination programs for adolescents.¹ At various times, some of Australia’s eight states and territories have opted for clinic-based programs, which may appear preferable for reasons of cost and the organisational challenges of school programs. However, the superiority of school-based delivery in achieving substantially higher coverage of adolescent vaccines (e.g.3-dose hepatitis, dTap) was clearly established through dedicated implementation research in the early 2000’s. In 2007, all eight Australian jurisdictions moved to implement school programs for adolescent vaccines recommended in the National Immunisation Program (NIP).¹ Australia’s national school-based vaccination program is funded by a combination of federal (cost of vaccine) and state (cost of program delivery) funds. Specialist immunisation nurses provide safe in-school vaccination clinics for consenting students. Specific strategies for education, consent and mop-up of missed doses vary by jurisdiction.²

The change to consistent in-school vaccine delivery of adolescent vaccines in Australia coincided with the introduction of the publicly funded National HPV Vaccination Program in early 2007. This program initially targeted school girls in the first year of high school (year 7 or 8). ‘Catch up’ vaccination of young women up to age 26 was also provided for 2 years until the end of 2009: this occurred through schools for girls in years 8-12. This strategy was designed to achieve high coverage in the highest risk age-group in a short time frame. For reasons of access equity, HPV vaccination of adolescent males was added to the NIP from 2013,³ with a more limited in-school catch-up.

School delivery of adolescent vaccination is the foundation of Australia’s success in achieving high HPV vaccine coverage at the national level from its inception (83% and 70% for course initiation and completion respectively in females up to age 17).⁴ High coverage in males and females has been maintained and even increased over the past decade. In age groups offered vaccination, there has been sustained and marked reductions in genital warts in males and females, HPV vaccine type prevalence and high-grade cervical intraepithelial lesions.⁵ Genital warts, previously the most common reason for a presentation to a sexual health clinic by young people are now a rare occurrence in Australia.

At the national level, there is some variation in vaccination uptake across jurisdictions, geographical regions and by socio-economic disadvantage.^4,6 The reasons for socio-demographic and also school-level variations are unclear, but likely to result from relative access barriers, which include variations in program organisational factors (e.g. consent and in school mop-up vaccination processes); knowledge and attitudinal barriers,⁷ and factors intrinsic to the school and its engagement with the program.

Parents have consistently shown high levels of support for school-based vaccination in Australia, for reasons of convenience and confidence in the process.⁸ Indeed, the school setting acts as a key facilitator of vaccination: while there is high community support for school vaccination, and the vast majority of young adolescents are in schools (98.5% of 14-year-olds), the normative influences are strong. Safety is of high importance to public support for vaccination and Australia has had a relatively uneventful HPV vaccination program over the past 11 years. The most common severe adverse event experienced by adolescents in Australia’s school program is syncope, consistent with other vaccines administered to this age group.⁹ Fear of the needle and syringe is a common concern reported by adolescents (all genders), parents, teachers and immunisation nurses.¹⁰ Therefore strategies to reduce adolescent anxiety are important. We have demonstrated that well designed education can support adolescent confidence on vaccination day, promote positive attitudes and increase understanding of vaccination, and is feasible to implement alongside the vaccination program.¹¹

The enduring success of Australia’s national HPV school-based vaccination program depends on ongoing public support for school vaccination and linked to this is the need for a better understanding of underlying mechanisms of success.^7,11,12 Strong cooperation between education and health sectors, understanding the effective program organisational strategies7 and attention to how the characteristics of schools themselves may either support or hinder on-site vaccination programs are needed, to ensure vaccination success in school settings.

DISCLOSURE
SRS has received institutional grants from Seqiris Australia; honoraria and travel reimbursement to educational meetings from Merck; Australian Government funded partnership grant with Vaxxas Pty Ltd. The rest of authors have nothing to disclose.

ARTICLES INCLUDED IN THE HPW SPECIAL ISSUE ON HPV VACCINATION AND PEDIATRICS:

K Pollock. Adolescent male vaccination in the United Kingdom- a victory for equality

LP Gordon, DR Platt, N Ramsey. HPV Vaccine: It Is Not Just a Girl Thing

T Wolynn. Kids Plus Pediatrics

References

1. Ward, K., et al., A history of adolescent school-based vaccination in Australia. Commun Dis Intell Q Rep, 2013. 37(2): p. E168-74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24168091

2. Ward, K., et al., Adolescent school-based vaccination in Australia. Commun Dis Intell Q Rep, 2013. 37(2): p. E156-67. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24168090

3. Georgousakis, M., et al., Population-wide vaccination against human papillomavirus in adolescent boys: Australia as a case study. Lancet Infect Dis, 2012. 12(8): p. 627-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22445354

4. Brotherton, J.M., et al., Human papillomavirus vaccine coverage among female Australian adolescents: success of the school-based approach. Med J Aust, 2013. 199(9): p. 614-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24182228

5. Patel, C., et al., The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent? Euro surveillance, 2018. 23(1): p. 1700737. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30326995

6. Barbaro, B. and Brotherton, J.M. . Assessing HPV vaccine coverage in Australia by geography and socioeconomic status: are we protecting those most at risk? Aust N Z J Public Health, 2014. 38(5): p. 419-23. Available from: & Gynecology 2018;132(2):261-270. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24962721

7. Cooper Robbins, S.C., Ward, K. and Skinner, S.R. School-based vaccination: a systematic review of process evaluations. Vaccine, 2011. 29(52): p. 9588-99. Available from: https://pubmed.ncbi.nlm.nih.gov/22033031/

8. Marshall, H.S., et al., Parental and societal support for adolescent immunization through school-based immunization programs. Vaccine, 2013. 31(30): p. 3059-64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23664996

9. National Centre for Immunisation Research and Surveillance, Evaluation of the National Human Papillomavirus Vaccination Program Final Report. 2014, Australian Government Department of Health: Canberra, Australia. p. 109-129. Available from: https://www.health.gov.au/resources/publications/evaluation-of-the-national-hpv-program-final-report

10. Bernard, D.M., et al. The domino effect: adolescent girls' response to human papillomavirus vaccination. Med J Aust, 2011. 194(6): p. 297-300. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21426284

11. Skinner, S.R., et al. HPV.edu study protocol: A cluster randomised controlled evaluation of education, decisional support and logistical strategies in school-based Human Papillomavirus (HPV) Vaccination of adolescents. BMC Public Health, 2015. 15(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/26373926

12. Davies, C., et al. ‘Is it like one of those infectious kind of things?’: The importance of educating young people about HPV and HPV vaccination at school. Sex Education, 2017. 17(3): p. 256-275. Available from: https://www.tandfonline.com/doi/full/10.1080/14681811.2017.1300770