Assessment of eight HPV vaccination programs implemented in lowest income countries.

BACKGROUND: Cervix cancer, preventable, continues to be the third most common cancer in women worldwide, especially in lowest income countries. Prophylactic HPV vaccination should help to reduce the morbidity and mortality associated with cervical cancer. The purpose of the study was to describe the results of and key concerns in eight HPV vaccination programs conducted in seven lowest income countries through the Gardasil Access Program (GAP). METHODS: The GAP provides free HPV vaccine to organizations and institutions in lowest income countries. The HPV vaccination programs were entirely developed, implemented and managed by local institutions. Institutions submitted application forms with institution characteristics, target population, communication delivery strategies. After completion of the vaccination campaign (3 doses), institutions provided a final project report with data on doses administered and vaccination models. Two indicators were calculated, the program vaccination coverage and adherence. Qualitative data were also collected in the following areas: government and community involvement; communication, and sensitization; training and logistics resources, and challenges. RESULTS: A total of eight programs were implemented in seven countries. The eight programs initially targeted a total of 87,580 girls, of which 76,983 received the full 3-dose vaccine course, with mean program vaccination coverage of 87.8%; the mean adherence between the first and third doses of vaccine was 90.9%. Three programs used school-based delivery models, 2 used health facility-based models, and 3 used mixed models that included schools and health facilities. Models that included school-based vaccination were most effective at reaching girls aged 9-13 years. Mixed models comprising school and health facility-based vaccination had better overall performance compared with models using just one of the methods. Increased rates of program coverage and adherence were positively correlated with the number of vaccination sites. Qualitative key insights from the school models showed a high level of coordination and logistics to facilitate vaccination administration, a lower risk of girls being lost to follow-up and vaccinations conducted within the academic year limit the number of girls lost to follow-up. CONCLUSION: Mixed models that incorporate both schools and health facilities appear to be the most effective at delivering HPV vaccine. This study provides lessons for development of public health programs and policies as countries go forward in national decision-making for HPV vaccination.

Uptake of trichiasis surgical services in Tanzania through two village-based approaches.

AIM: To determine the effectiveness of village-based strategies (using school teachers and village leaders) to increase the use of surgical services. METHODS: A cohort study was conducted in Tanzania using two village strategies (village leader and school teachers); trichiasis surgical uptake and the factors associated with uptake were measured after 1 year. RESULTS: The trichiasis surgical coverage at baseline was 16.9%; 200 patients who needed surgery were identified. One year later, we were able to re-examine and interview 163 of these patients. The surgical uptake among these patients was 44.8% (95% CI 37.2% to 52.4%). Patients in the school-teacher programme had a 36.5% uptake compared with 52.1% for those in the village-leader programme. No difference was observed in uptake by age or sex. Uptake was highest among those coming from multiple-generation households and those with more household wealth. Of the 90 people who still had not had surgery, 20 (22.2%) reported seeking surgery, but failing to receive it because of barriers at the provider side. CONCLUSIONS: Improved surgical uptake for trachomatous trichiasis was achieved by using village-based promotion efforts and surgical services at existing health clinics. Even with free surgery at health clinics, indirect costs and social support barriers limit utilisation by the most vulnerable, the poorest and those living in single-generation households. Problems at the provider level also create barriers for patients who need surgery.

Does clinical diagnosis indicate ocular chlamydial infection in areas with a low prevalence of trachoma?

The WHO has initiated a global program to eliminate trachoma. This program includes mass antibiotic administrations to reduce the prevalence of Chlamydia trachomatis, the causative agent in trachoma. DNA amplification tests are the most sensitive methods to diagnose C. trachomatis infection, but are expensive and not typically performed in trachoma-endemic areas. Trachoma programs use clinical examination to determine which communities and which individuals within communities would benefit from antibiotic treatment, so understanding the relationship between clinical activity and chlamydial infection is important. In this study, we determine what percent of individuals with clinically active trachoma are infected with chlamydia in low prevalence communities of China and Nepal (with <10% clinical activity in children), and compare this against a high prevalence community of Nepal (with >30% clinical activity in children). In the low prevalence areas, only 8% clinically active cases had evidence of chlamydia. In the high prevalence community, 70% of clinically active cases harbored chlamydia. These results imply that clinical activity is less indicative of infection at a lower prevalence. In the context of a trachoma program, both clinically active cases and the community as a whole may stand to benefit less from antibiotic treatment in lower prevalence areas.