<![CDATA[How Ireland reversed a HPV vaccination crisis]]>

In line with recommendations from the World Health Organization, a human papillomavirus (HPV) school based vaccination programme began in Ireland in 2010.

HPV4 vaccine (Gardasil) vaccine is offered to all girls in first year of second level school (age 12- 13 years) to protect them from cervical cancer in adulthood. The vaccine course starts in September/October and is completed during the academic year.

The programme was immediately successful and uptake of the completed course exceeded the target of 80% increasing to 86.9% in 2014/15 (Figure1)¹. There was no difference in the rates in schools with different religious ethos although disadvantaged schools had a lower mean uptake (%) compared to other schools in 2013/14 (79.4% versus 85.0%, difference 5-58%, 95% CI 2·69-8·21).²

The situation changed in 2015 when some parents established lobby groups because they were concerned they were not given correct information about vaccine safety. These groups built a strong social media platform, overwhelming parents with striking personal experiences from vaccinated girls, negative information and “facts”. Politicians were also lobbied with this misinformation and there was widespread coverage in local and national media. In December 2015, a documentary “Cervical cancer vaccine – is it safe” aired on national television based on a similar programme shown in Denmark.

This had a dramatic impact. The uptake of the completed course in 2015/2016 dropped to 72.3% and in 2016/17 the estimated uptake of the first dose plummeted to 50% with all parts of the country affected.

While many studies have shown school immunisation programmes to be superior to clinic-based or primary care-based programmes in achieving high uptake³, the lack of direct contact with parents made it difficult to win back trust. To overcome this, a steering group of concerned organisations was established in early 2016 to identify key stakeholders and ask them to actively promote the vaccine.

Parental views about HPV vaccine were explored in focus group discussions and an audit of our information materials was conducted to see how they compared with those from other countries with school based programmes that had maintained high vaccine uptakes. We also engaged in social media listening and analysis.

As a result, we revised our information materials for parents and included quotes from vaccinated girls, their mothers, national, international experts and the World Health Organization (WHO). We also revised our online content and developed short videos for our website www.hpv.ie which is regularly updated and which has been accredited by WHO as providing reliable information on vaccine safety.

Ongoing training for the school vaccination teams was enhanced and a national conference held with national and international speakers which proved pivotal in supporting and empowering the front line teams. As there is evidence that a recommendation from a trusted health professional is very influential in con- vincing parents about vaccination, we collaborated with our primary care colleagues and implemented a training programme on HPV vaccine and communication and developed elearning modules. Fact sheets and posters were sent to all general practitioners and pharmacists to help in advocating the vaccine.

Liaison between school authorities, teachers and parents associations was enhanced with frequent presentations updating them about the vaccine, information leaflets sent to teachers and lessons developed on the safety of HPV vaccine and separating facts from fiction. The HPV Vaccination Alliance was launched in July 2017. This is a group of over 35 different organisations working in areas including health, cancer control, education, women’s rights, child welfare and youth support, each of whom has pledged to raise awareness of HPV vaccine and its benefits in stopping cancer and saving lives.

The 2017/18 HPV vaccination programme was launched by the Minister for Health supported by senior politicians who have all been actively promoting the vaccine. A media campaign featuring vaccinated girls ran on local and national radio and social media. This was enhanced in 2018 by the intervention of a 25 year old Irish woman diagnosed with terminal cervical cancer as a very powerful vaccine advocate featuring in a further media campaign, appearing on national television and with an extensive social media following.

All this activity has had a positive impact. Media coverage is now pro vaccine and our stakeholders and other members of the general public respond rapidly to any anti vaccine sentiment.

The vaccine was offered again to girls who had refused or not consented and the first dose uptake increased in 2016/17 to 55.8% and to an estimated 61.7% in 2017/18 (Figure 2). Further increases are expected in the coming months.

The crisis of confidence in HPV vaccine that occurred in Ireland has been reversed through cross sector collaboration with a wide range of stakeholders within a short time frame. Other countries that have had similar crises such as Japan and Denmark have not seen such a rapid turnaround.

We hope that publication of the lessons learned from Ireland can help other countries as we all strive to reduce morbidity and mortality from cervical cancer.⁴

References

1. HPV immunisation uptake statistics. Health Protection Surveillance Centre. 2018. Dublin: http://www.hpsc. ie/a-z/vaccinepreventable/ vaccination/immunisationuptakestatistics/ hpvimmunisationuptakestatistics/.
2. Migone C, Barrett T, Cotter S, et al. The Uptake of Human Papillomavirus Vaccine In Irish Schools: The Impact Of Disadvantage. Ir Med J 2017; 110 (7): 603.
3. Joyce-Cooney J, Meagher G, Quinn C, et al. Achieving 95% uptake in an immunisation programme--not an impossibility. J Ir Med J. 2003;96(9):268-70.
4. Corcoran B, Clarke A, Barrett T. Rapid response to HPV vaccination crisis in Ireland. The Lancet 2018;391(10135):2103.

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Brenda Corcoran, MPH, FFPHMI
Consultant in Public
Health Medicine
National Immunisation
Office Dublin D07X320, Ireland
brendamcorcoran@gmail.com

Anna Clarke, MPH, MD
Consultant in Public Health
Medicine
National Immunisation Office
Dublin D07X320, Ireland
clarke.annat@gmail.com

Tom Barrett, MRCOG
Senior Medical Officer
National Immunisation Office
Dublin D07X320, Ireland
tom.barrett@hse.ie

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