Elsevier

Vaccine

Volume 33, Issue 31, 17 July 2015, Pages 3726-3730
Vaccine

Introduction of a National HPV vaccination program into Bhutan

https://doi.org/10.1016/j.vaccine.2015.05.078Get rights and content

Highlights

  • Bhutan was the first low/middle-income country to introduce national HPV vaccination.

  • A school-based campaign achieved over 90% vaccine coverage in 12–18 year-old girls.

  • Vaccine coverage was higher among 12 year old (∼100%) than 13–18 year-old (89%) girls.

  • Health-center-based delivery achieved lower vaccine coverage (∼70%) than school-based.

  • Bhutan's experience is valuable for other countries implementing HPV vaccination.

Abstract

Background

Cervical cancer is the most common cancer in Bhutanese women. To help prevent the disease, the Ministry of Health (MoH) developed a national human papillomavirus (HPV) vaccine program.

Methods

MoH considerations included disease incidence, the limited reach of cervical screening, poor outcomes associated with late diagnosis of the disease, and Bhutan's ability to conduct the program. For national introduction, it was decided to implement routine immunization for 12 year-old girls with the quadrivalent HPV6/11/16/18 (QHPV) vaccine and a one-time catch-up campaign for 13–18 year-old girls in the first year of the program (2010). Health workers would administer the vaccine in schools, with out-of-school girls to receive the vaccine at health facilities. From 2011, HPV vaccination would enter into the routine immunization schedule using health-center delivery.

Results

During the initial campaign in 2010, over 130,000 doses of QHPV were administered and QHPV 3-dose vaccination coverage was estimated to be around 99% among 12 year-olds and 89% among 13–18 year-olds. QHPV vaccine was well tolerated and no severe adverse events were reported. In the three following years, QHPV vaccine was administered routinely to 12 year-olds primarily through health centers instead of schools, during which time the population-level 3-dose coverage decreased to 67–69%, an estimate which was confirmed by individual-level survey data in 2012 (73%). In 2014, when HPV delivery was switched back to schools, 3-dose coverage rose again above 90%.

Discussion

The rapid implementation and high coverage of the national HPV vaccine program in Bhutan were largely attributable to the strength of political commitment, primary healthcare and support from the education system. School-based delivery appeared clearly superior to health centers in achieving high-coverage among 12 year-olds.

Conclusions

Bhutan's lessons for other low/middle-income countries include the superiority of school-based vaccination and the feasibility of a broad catch-up campaign in the first year.

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.

Section snippets

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

References (21)

  • E.J. Crosbie et al.

    Human papillomavirus and cervical cancer

    Lancet

    (2013)
  • J. Ferlay et al.

    GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide: IARC CancerBase No. 11 [Internet]

    (2013)
  • Ministry of Health

    Bhutan health management information system

    Annual health bulletin 2012

    (2012)
  • Bhutan Reproductive Health Programme Review Report,...
  • I. Baussano et al.

    Cervical cancer screening program in Thimphu Bhutan: population coverage and characteristics associated with screening attendance

    BMC Womens Health

    (2014)
  • Ministry of Health

    National health survey

    (2012)
  • T. Tobgay et al.

    Progress and delivery of health care in Bhutan, the land of the thunder dragon and gross national happiness

    Trop Med Int Health

    (2011)
  • T. Tobgay et al.

    Health and gross national happiness: review of current status in Bhutan

    J Multidiscip Healthc

    (2011)
  • GAVI honours 15 countries for excelling in immunization and child survival. 19-11-2009....
  • World Health Organization

    Human papillomavirus vaccines. WHO position paper

    Wkly Epidemiol Rec

    (2009)
There are more references available in the full text version of this article.

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