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C Vujovich-Dunn et al. (July 2023). Enhancing Australian monitoring and evaluation systems to support equitable HPV vaccination. www.HPVWorld.com, 239

Cervical cancer is preventable and the elimination of cervical cancer as a public health problem (incidence <4/100,000) is a global health priority¹. To achieve cervical cancer elimination, the World Health Organization global strategy proposes coverage targets by 2030: 90% of girls vaccinated by age 15; 70% of women screened with a high-precision test at age 35 and at age 45, and 90% received treatment¹. Although Australia has a well-established school-based HPV vaccination program, internationally acclaimed due to early successes, coverage varies with Australia’s national register showing only 81% of girls had completed their HPV vaccine course in 2020², compared to >95% coverage for childhood vaccinations. Despite relatively high national rates of coverage, stubborn coverage gaps remain, with little known about the characteristics of population groups with the lowest coverage, and the local barriers. Gaps in coverage limit population immunity, leaving many at risk of developing cervical and other HPV-related cancers.

In response, we analysed school-level HPV vaccination data across three jurisdictions in Australia, for the first time. We focused on HPV initiation dose coverage, rather than completion^3-5. We observed the strongest associations with low coverage for smaller schools and schools caring for adolescents with special education needs, followed by schools with a higher proportion of Indigenous adolescent enrolments, schools with lower attendance rates, schools in remote locations and schools in lower socioeconomic areas. However, the prevalence of these factors varied across the population. Combining the effect size and the prevalence of these factors, our school-level attributable risk analysis identified school characteristics which accounted for the largest proportion of low coverage: smaller schools (79%) followed by schools with higher Indigenous enrolments (38%) and then schools with lower attendance rates (37%) (Figure 1)⁵. Undertaking the analysis at the school-level provided new information about the main vaccine delivery strategy for adolescents in Australia, and which schools to prioritise for interventions. However, there remains a gap in understanding the uptake and predictors of HPV vaccination among specific subgroups attending many different schools. This information is critical to appropriate co-design interventions tailored to the subgroups needs.

There is an urgent need for individual-level data to allow the robust identification of population groups with lower coverage. The 2021 impact evaluation of the Australian national HPV vaccination program found that vaccine coverage was lower for people residing in lower socioeconomic areas (63%), for remote residents (61%), and for Aboriginal and Torres Strait Islander peoples living in Western Australia (55%)². The main limitation of this analysis is that the Australian Immunisation Register collects a limited number of socio-demographic variables for each individual (age, sex, postcode, Aboriginal and Torres Strait Islander status). There are no data on people with a disability, or culturally and linguistically diverse communities, the data on Aboriginal and Torres Strait Islander status is incomplete (30% missing), and the data for socioeconomic status are area-based².

A variety of factors are likely to influence vaccination coverage rates, including social determinants of health such as income, geographic location, education, and level factors. How these factors contribute to HPV vaccination uptake in Australia is not known. The need for more granular individual-level data is reflected in recommendations from the most recent national cervical cancer prevention reports and the technical paper informing Australia’s national elimination strategy². These data are required to underpin the design and implementation of interventions (with an emphasis on the initiation dose) in under-immunised populations and achieve equitable HPV vaccination coverage and cervical cancer prevention. 



One mechanism to achieve this is to draw on the Multi-Agency Data Integration Project (MADIP), a new Australian national person-level longitudinal enduring linked data resource combining information on health, vaccination, sociodemographic, education, disability, taxation, and social service payments. The MADIP datasets are linked routinely by the Australian Bureau of Statistics. This integrated population-based data would allow us to document the sociodemographic, household, and healthcare factors that predict participation in vaccination and help untangle intersectionality.

In conclusion, in Australia we have made progress in achieving high levels of HPV vaccination nationally, however, due to low coverage in some population groups, we need to enhance our monitoring and evaluation systems to ensure we equitably achieve the WHO targets. This includes capturing social determinants to ensure we identify barriers that create discrimination and disadvantage and impede the uptake of vaccination.

CONFLICT OF INTEREST STATEMENT
Authors have no conflicts of interests to disclose.


References

1. K Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020. Available from: https://www.who.int/publications/i/item/9789240014107

2. National Centre for Immunisation Research and Surveillance. Impact evaluation of Australian national human papillomavirus vaccination program 2021. Available from: https://ncirs.org.au/sites/default/files/2021-02/Impact%20evaluation%20of%20national%20HPV%20vaccination%20program_February%202021_Report.pdf

3. Sisnowski J, Vujovich-Dunn C, Gidding H, et al. Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states. Vaccine. 2021;39(41):6117-6126. Available from: https://www.sciencedirect.com/science/article/pii/S0264410X21011245

4. Vujovich-Dunn C, Skinner SR, Brotherton J, et al. School-Level Variation in Coverage of Co-Administered dTpa and HPV Dose 1 in Three Australian States. Vaccines. 2021;9(10). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537995/

5. Vujovich-Dunn C, Wand H, Brotherton JML, et al. Measuring school-level attributable risk to support school-based HPV vaccination programs. BMC public health. 2022;22(1):822. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-13088-x



This article is included in the HPW Special Issue Prevention of HPV-related diseases in Australia

Scientific coordinators:
Suzanne Garland, Dorothy Machalek, Cristyn Davies, Xavier Bosch

HPW editors:
Marisa Mena, Patricia Guijarro, Paula Peremiquel

On behalf of the editorial team, we would like to thank all the authors who contributed to this special issue of HPW



OTHER ARTICLES IN THIS HPW SPECIAL ISSUE:

D Machalek, C Davies. Australia’s HPV Vaccination Program: 15 years of success

I Frazer, S Garland. HPV eradication: targets for the century

D Machalek, K Sharma, J Kaldor. Tracking the impact of HPV vaccination on infection prevalence to measure vaccination program success

E Chow, J McCloskey. HPV vaccination is highly effective at preventing genital warts

O McNally, R McBain, KL Talia. Prevention of vulvar, vaginal precancer and cancer

R Hillman, M Poynten. Prevention of anal cancer

D Novakovic, A Cheng. Prevention of recurrent respiratory papillomatosis with HPV vaccination

C Davies, SR Skinner. School-based vaccination is key to reducing HPV-related diseases

J Brotherton, M Saville, D Wrede. Prevention of cervical precancer and cancer

M Smith, L Whop, J Brotherton. Cervical cancer elimination: true success requires equity