HPV vaccination in the UK

Abstract

Acceptable uptake is possible in schools, but important practical barriers exist

In the accompanying study, Brabin and colleagues report findings from a pilot study of routine human papillomavirus (HPV) vaccination in advance of the implementation of a £100m (€124m; $197m) national HPV immunisation programme in the United Kingdom this autumn.¹ The study achieved 70.6% uptake for the first dose of the vaccine, with a drop of only 2.1% for the second dose. The third dose has yet to be delivered, and the authors emphasise the crucial importance of maintaining high uptake for the final dose.

These are the first published data on the uptake of HPV vaccine, and they are both encouraging and consistent with studies of intentions to vaccinate in the UK and elsewhere.^{2 3 4} However, uptake was lower than the 87.2% achieved in the same age group for a school based meningitis C catch-up programme in 2000,⁵ or the 91% uptake of the first dose in a comparable study of hepatitis B vaccination. ¹

Achieving acceptable coverage in the absence of national publicity, and before HPV vaccination becomes a normative part of the immunisation schedule, is encouraging. However, we must be cautious about generalising from the primary care trusts and schools that elected to take part in this study, as they are likely to provide a more positive environment for delivering the vaccine.

The study identified some logistical challenges for national implementation. A substantial proportion of girls received the first (16.3%) dose and second (23.6%) dose later than planned, and this number will probably be equally high for the third dose. Vaccinating these girls outside the scheduled sessions necessitated a flexible implementation strategy, and this may be more difficult in routine practice. If this is the case, the present results could overestimate the uptake that can be expected across the country. When the programme is implemented nationwide, general practitioners will be involved in immunising girls who miss the vaccine in school, and from 2009, they will also be involved in immunising girls who are no longer at school but are eligible for the catch-up programme. The likely coverage in primary care remains unknown.

Concerns about safety and efficacy were the main reasons that parents cited for refusing consent—consistent with studies of acceptability.^{2 3 6 7} This is to be expected given that, as yet, no data are available on the long term efficacy or adverse effects for either of the candidate vaccines. Exploring such concerns will be key to understanding the reasons for refusal. One study found that mothers who believed that their general practitioner took their concerns about vaccinations seriously were more likely to intend accepting the HPV vaccine.⁸ This shows how important it is that general practitioners listen to parents’ views and talk about their concerns. However, in the wake of the controversy about the measles, mumps, and rubella (MMR) vaccine, work needs to be done to restore public confidence in immunisation.

Only four parents (0.1%) cited fears about condoning sexual activity as a reason for refusing consent. The notion that vaccinating against a sexually transmitted infection might encourage risky sexual behaviour (so called “risk compensation”) has received media and academic interest. At present, though, it is unclear whether and when this phenomenon occurs, or if fear of risk compensation is a significant barrier to acceptance of vaccination.^{9 10} However, given that 20% of parents in Brabin and colleagues’ study passively refused the vaccine, giving no reason, risk compensation beliefs may be more prevalent than the figures suggest. More work is needed to understand the motives for passive refusal of the vaccine and the practical barriers to providing consent.

Some of the girls whose parents refused consent might have wished to be vaccinated, and it could be argued that 12-13 year old girls are “Gillick compentent” to make this decision for themselves.¹¹ It is not clear how best to balance girls’ own wishes and the possibility of increasing uptake against parents’ desire to be involved in the decision making process, or school nurses’ likely preference for written parental consent.¹² Decisions need to be made about whether girls should have access to the vaccine through primary care if their parents have refused consent via the school based programme.

As with many new health technologies, uptake of the vaccine in this study was highest in girls from affluent, white backgrounds, who have the lowest incidence of cervical cancer. In addition, cultural or religious beliefs seem to have been important, with two schools refusing to participate in the study on religious grounds. It is essential to engage with groups and communities who have concerns about the vaccine and take steps to ensure that existing disparities are not widened by inequitable uptake. Problems with access and delivery can be tackled partly by sharing best practice from areas that achieve high uptake, but parental concerns also need to be identified and dealt with. As the immunisation programme is implemented across the country, monitoring uptake and identifying subgroups in which uptake is particularly low will be vital.