Human Papillomavirus vaccination campaign in England

From Ganfyd

Information on this page applies to the HPV vaccination campaign in England only

For general information about the virus, see the Human papillomavirus (HPV) page.

The government plans to introduce vaccination for all girls aged 12-13 (school year 8) from September 2008,^[1][2] based on JCVI reccomendations.^[3] It was announced on 21 July 2008 that the deal on the vaccine was sufficiently better than originally expected, that there were sufficient funds to offer the vaccine to all girls in school year 13 (age 17-18) in 2008.^[4] Starting the following year there will be a two-year catch-up programme, offering the vaccine to all girls up to the age of 18. Further details, including funding, have been partially announced in a letter from David Salisbury.^[5]

A new (draft) chapter (chapter 18a) for the Green Book has been published and can be downloaded here,^[6] and other materials are published at the department's immunisation website, at a new HPV microsite.

Who will be offered the vaccine?

Essentially, all girls will be offered the vaccine when they are in school year 8 (those whose thirteenth birthday happens during the year starting on 1 September and finishing on 31 August the following year). There will also be a "catch-up programme" to vaccinate older girls. Eventually all girls born between on or since 1 September 1990 should have been offered the vaccine.

Other people can and should be offered the vaccine, but this would be outside the planned vaccination programme. See the Human papillomavirus vaccine page for more information.

The plan, as updated on 22 December 2008

On 22 December 2008 it was announced that the catch-up programme, which was due to be undertaken over two years (the 2009-2010 and the 2010-2011 school years) would be compressed into one year - the 2009-2010 school year. This means that all girls in school years 10 to 13 (typically born on or between 1 September 1991 and 31 August 1995) will be offered the vaccine during the 2009-2010 school year.^[7][8]

The plan, as updated on 19 June 2008

In addition to the plan as previously, girls in year 13 (upper sixth in old money!) - those with date of birth on or between 1 September 1990 and 31 August 1991 were to be offered the vaccine in the 2008-2009 school year.^[9]

The original plan.

The original plan was to vaccinate:^[10]

1. Girls who are in year school year 8, starting in Autumn 2008, and continuing indefinitely (that is, girls whose date of birth is on or after 1/9/1996 to 31/8/1997.)
2. Girls who are in school years 12 and 13, during the 2009-2010 academic year. Those girls' dates of birth are from 1/9/1992 to 31/8/1993 inclusive (year 13), and from 1/9/1993 to 31/8/1994 inclusive (year 12).
3. Girls who are in school years 11 and 12, during the 2010-2011 academic year. Those girls' dates of birth are from 1/9/1994 to 31/8/1995 inclusive (year 12), and from 1/9/1995 to 31/8/1996 inclusive (year 12).

So all girls with a date of birth on or after 1/9/92 should be offered the vaccine, although some of them will be nearly 18 (possibly older) by the time they finish the course.

Which vaccine will be used

The vaccine chosen for the programme is Cervarix™. This will change to Gardasil™ from September 2012.

Some have argued that Gardasil™ should have been used from the inauguration of the programme as GlaxoSmithKline's Cervarix™ provides no protection against genital warts, unlike Sanofi Pasteur MSD's Gardasil™.

The initial decision to use Cervarix™ seems to have been based on a conclusion that difference in the value of the deals offered by the two manufacturers exceeded the anticipated cost-savings from treating fewer cases of genital warts, but this is clouded by "commercial in conference" rules which prevent public scrutiny of the deals on offer. This is discussed in more detail on the Human papillomavirus vaccine page.

When will the programme start?

The programme started on 1 September 2008, and the catch-up programme is due to start on 1 September 2009 (that's this far away).

Where will the vaccination be done?

This will have to be decided locally.

Options include:

1. Giving all the vaccinations in schools.
2. Giving all the vaccinations in primary care (GP surgeries).
3. Giving all the vaccinations in special vaccination clinics.
4. Some combination of the above.

Vaccinating in schools

There is an argument that vaccinations are best given in schools. Experience from the "school leaver booster" is that vaccine uptake appears to be higher where it is given in schools, than where it is given by GP practices - although it is possible that it is just the recording of uptake that is better (i.e. that where vaccination is done in GP practices the uptake rate is just as high, but the data is not recorded in a way that reaches the national databases). In previous vaccination campaigns, including the MR campaign in 1994 (see Questions_and_answers_about_mumps_and_MMR) and the meningococcal group C conjugate vaccine campaign in the late 1990s, vaccination in schools was considered to have been cheap - and it was considerably cheaper for the Department of Health, as considerably less was paid to Health Authorities (HAs) for jabs given in schools than was paid to GPs for jabs given in practices. (In reality, HAs often had to contribute, or other work had to be left undone; but nevertheless, the amount paid by the tax-payer was less than for jabs given in practices.)

It seems likely that where there is a "captive audience" - girls already present in schools - that uptake is likely to be higher.

If vaccination is to be given in schools, a number of issues need to be considered. They include:

• Do additional staff need to be trained and appointed to do this? Since routine BCG vaccination of teenagers was stopped recently (XXX check date), many of the staff who were trained and accustomed to doing vaccination in schools have been redeployed or left the service.
• Will the schools agree to the vaccination being done in schools? Each girl will need three jabs (at 0, 2, and 6 months if Gardasil is to be used), so the campaign will be quite intrusive for schools.
• Are the staff who know how to organise this sort of campaign still available? The last such campaign took place in the last century; and the BCG programme has not been running for some time. There are all sorts of practical issues to be sorted out, such as:

• Vaccine storage and supply.
• Ensuring that suitable educational materials are made available to girls and their parents prior to vaccination.
• Obtaining and recording informed consent.
• Recording vaccine uptake.
• Arrangements for those who miss vaccination sessions (but still want the vaccine).
• Teenage girls are particularly susceptible to mass psychogenic illness, so outbreaks of fainting and other psychogenic symptoms might be more of a problem vaccination is delivered in schools.

Vaccination given in general practice

There may be arguments for doing the vaccination in general practice.

Some vaccination may have to be done in this setting, if only for girls who miss their vaccination in schools.

Vaccination given in general practice

There may be arguments for doing the vaccination in special vaccination clinics; and some PCTs may choose to provide some (probably catch-ups) or all of the vaccination in this setting.

Recording vaccination

Ideally, all vaccinations should be recorded in such a way that will allow later record-linkage, to evaluate the vaccination programme. Specifically, we will need to be able to answer the following questions:

• What is the uptake rate?

• Are there geographical or other variations?

• How effective is an incomplete series of vaccinations? - we will need to know how many jabs each recipient received.
• What is the rate of adverse events following vaccination, and how does this compare with the expected rate assuming no vaccination is given. (In the USA the anti-vaccine lobby tried to suggest that adverse events that happened after vaccination were caused by the vaccination, even though in several cases there was no plausible link, and the rate was no higher than would have been expected in unvaccinated girls).
• What is the rate of outcomes that might be prevented by vaccination - abnormal smears (by type of abnormality), cases of cervical cancer, cases of genital warts, cases of anal warts, penile warts, and other diseases caused HPV.

Consent

There is an argument that most girls aged 13 or more can understand the issues around vaccination; and, especially since vaccination is in their best interests, girls of this age should be generally be considered competent to give consent (as long as there is no concern expressed e.g. by school staff that a particular girl is unlikely to be competent).

Nevertheless, girls of under 16 are technically minors, and many would be more comfortable if parental consent were obtained and recorded prior to vaccination.

Funding arrangments

According to the David Salisbury letter:^[11]

"£8.9m will be transferred to PCTs to support the implementation of the programme, with funding allocated on a per capita basis. This equates to just over £55k for an average sized PCT. This funding will support PCTs in making suitable arrangements including..."

A more detailed list was circulated in a subsequent letter, giving the number of 12- 13-year-old girls (school year 8) in each PCT, and suggesting that PCTs will receive £29:16 per girl in this age group.^[12]

External links

• Presentations and information from conferences on HPV for immunisation coordinators, organised by Department of Health, on 26 October 2007 and on 13 March 2008.

References