Introduction of a National HPV vaccination program into Bhutan
Introduction
In the Himalayan kingdom of Bhutan, cervical cancer is the most common cancer among women, with an age-standardized incidence rate of approximately 13 cases per 100,000 person years [1]. In 2011, cervical cancer accounted for 32% of all cancers affecting women between 15 and 64 years in Bhutan [2]. A large majority of cases are diagnosed with late stage cancer and the mortality associated with the disease is high [3]. Cases eligible for radiation/chemotherapy treatment are referred to India; the Government of Bhutan assumes the cost of such treatment (approximately USD 4000 per case). The country's cervical cancer screening program is expanding, but currently reaches less than half of women of eligible age [4], [5].
Despite limited resources, Bhutan has made a concerted effort to deliver healthcare free of charge to its approximate 720,000 population [6]. These efforts are guided, in part, through Bhutan's policy of “Gross National Happiness” [7], for which good health and access to health facilities are considered important sources of happiness. Healthcare services are delivered through 32 hospitals, 185 Basic Health Units and 519 outreach clinics that provide maternal and child health services in rural communities [2]. Despite this good network of health centers, access to primary health remains a challenge due to the terrain.
The country has made substantial progress in key health indicators. The Expanded Program on Immunization was established in Bhutan in 1979, and there has been consistently maintained high coverage with a routine immunization package and introduction of vaccines against hepatitis B in 1997, rubella and measles (2006), and Haemophilus influenza type b (re-introduction in 2011). Bhutan received in 2009, a Global Alliance for Vaccines and Immunization award for its outstanding performance in improving child health and immunization [8]. The existing program provided a basis for the implementation of primary cervical cancer prevention through HPV vaccination.
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The decision to introduce HPV vaccination
After consulting the World Health Organization (WHO) South-East Asia Regional Office in 2009, the MoH decided to implement a national HPV vaccine program based on the issues reported in Box 1.
According to WHO recommendations [9], Bhutan's National Committee on Immunization Practices (NCIP) decided that routine HPV immunization should be offered to girls aged 12 years. NCIP also opted for a one-time catch-up campaign targeting girls 13–18 years of age during the first year of the program in
Coverage rates in the first year of HPV vaccination
In the first dose round of the campaign, 44,849 girls aged 12–18 years were vaccinated with an estimated coverage rate of 92%. The second and third doses reached 43,695 (90%) and 43,863 (90%) girls, respectively (Table 1). Coverage was very high amongst the 12 year-old target population: 99% for first dose, and similarly high for the second and third doses. An accurate estimate of coverage by dose was hampered, however, by the lack of individual vaccination records and the fact that some girls
Discussion
Bhutan was the first low/middle-income country to successfully introduce the HPV vaccine into its routine immunization schedule through a national school-based catch-up campaign, and achieved an immunization coverage rate exceeding 90% among all 12–18 year-old girls in the country. Delivery of HPV vaccine in school was a key element to achieving high coverage, as coverage dropped when HPV vaccine was administered routinely to 12 year-old girls in health centers. HPV vaccine was found to be
Conclusions
The experience in Bhutan can be used as a model for other countries interested in implementing HPV immunization programs. Bhutan's lessons include the superiority of school-based vaccination and the feasibility of a broad catch-up campaign in the first year.
Authors’ contributions
TD, SP, TT and UT are experts in vaccination and/or cervical cancer prevention in the Bhutan MoH and were involved in the conception and/or implementation of the Bhutanese HPV vaccination program. TD drafted the current manuscript and coordinated the initial feasibility and implementation of the catch-up campaign in 2010 and the Paro pilot in 2009. SP was responsible for collating data on coverage and AEs, as well as overall co-ordination and implementation of the HPV vaccination program in
Conflict of interest statement
None.
Acknowledgements
Assistance to the HPV vaccination program came from MSD (provision of free vaccines in 2010 and technical support), ACCF (vaccine purchase for the first five years of the routine program), UNFPA (financial support during the mass catch-up campaign) and WHO (technical support). IARC investigators were supported by the Bill & Melinda Gates Foundation, USA (grant number OPP1053353). The funders had no role in the design of the study; the collection, analysis and interpretation of the data; the
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