Objective: The objective of this study is to assess the HPV vaccination coverage of 11-19-year-old girls during a state-coordinated HPV vaccination program in Geneva, Switzerland, from September 2008 to June 2011. Methods: State Medical Office coordinated the HPV vaccination program. Each service provider transmitted the list of the persons who had received their first, second, or third shot. Results: The global coverage rates, 3years after the program had been launched, were 63.72% for one dose, 63.22% for two doses, and 61.40% for three doses of the HPV vaccine. Conclusion: This study shows that it is possible to obtain a good coverage rates after 3years of a state-coordinated HPV vaccination progra

Chastonay, Philippe

Jeannot, Emilien

Sudre, Philippe

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BRIEF REPORTHPV vaccination coverage within 3 years of program launching(2008–2011) at Geneva State, SwitzerlandEmilien Jeannot • Philippe Sudre • Philippe ChastonayReceived: 3 February 2011 / Revised: 30 January 2012 / Accepted: 15 February 2012 / Published online: 28 February 2012 Swiss School of Public Health 2012AbstractObjective The objective of this study is to assess the HPVvaccination coverage of 11–19-year-old girls during astate-coordinated HPV vaccination program in Geneva,Switzerland, from September 2008 to June 2011.Methods State Medical Office coordinated the HPV vacci-nation program. Each service provider transmitted the list ofthe persons who had received their first, second, or third shot.Results The global coverage rates, 3 years after the programhad been launched, were 63.72% for one dose, 63.22% for twodoses, and 61.40% for three doses of the HPV vaccine.Conclusion This study shows that it is possible to obtaina good coverage rates after 3 years of a state-coordinatedHPV vaccination program.Keywords Immunization  Adolescent Human papilloma virusIntroductionThe human papilloma virus (HPV) is the most frequent causeof sexually transmitted infections in Switzerland (OFSP2008a). The HPV is responsible, exclusively or not, for a largenumber of pathologies: cervical carcinoma in situ or invasive(100% of the cases), cancers of the anus (90%), cancers of thepenis (40%), cancers of the vulva and the vagina (40%), andgenital condylomas (100%). There are more than 120 geno-types of HPV. HPV 16 and 18 are directly responsible for themajority of the cervical cancers, HPV 6 and 11 for the con-dylomas. These viruses are widespread and the infection,which generally goes unnoticed, can be transmitted during thefirst sexual intercourse. Cancers may develop 15–20 yearsafter infection (OFSP 2008a, b; WHO 2005).Cervical cancer is a major public health problem. Itaffects approximately 1.4 million persons worldwide, withan annual incidence of 500,000 cases (Simoens et al. 2009;WHO 2005). Worldwide, it is responsible for 274,000deaths per year. Cervical cancer is the second cause ofcancer for women in the world just after breast cancer(Wong et al. 2011). In Europe, cervical cancer affectsapproximately 60,000 women and is responsible for 30,000deaths every year (Simoens et al. 2009).In Switzerland, every year, 5,000 young women presenta precancerous lesion of the cervix or an in situ carcinomaand 320 an invasive cervical carcinoma requiring a surgi-cal/laser treatment. Half of the women presenting aprecancerous lesion of the cervix or an in situ carcinoma isless than 50 years old when the disease is diagnosed.In Geneva, there are approximately 400 cases of in situand 30 invasive cervix cancers every year, resulting in5–10 deaths per year (RGT 2009).The first vaccine to prevent cervical cancer and pre-cancerous genital lesions caused by human papilloma virus(Gardasil) was approved by the Swiss Drug RegulationAgency in 2006. To be completely effective, three vaccinedoses are recommended within 6 months and should beadministered before the beginning of sexual activity.E. Jeannot (&)  P. ChastonayFaculty of Medicine, Institute of Social and PreventiveMedicine, University of Geneva, Geneva, Switzerlande-mail: emilien.jeannot@unige.chP. SudreDepartment of the Regional Affairs, Economy and Health,Service of Epidemiology and Contagious Diseases,State Medical Office, Geneva, SwitzerlandE. JeannotDepartment of Public Instruction, School Health Service,Geneva, SwitzerlandInt J Public Health (2012) 57:629–632DOI 10.1007/s00038-012-0352-2123The aim of this study was to assess the HPV coverageamong 11–19-year-old girls (aged at the beginning of theprogram, in September 2008) in the Swiss canton ofGeneva.MethodsThe HPV vaccination program in GenevaThe Swiss Federal Vaccination Committee recommendedHPV vaccination free of charge for girls, aged 11 to 19(OFSP 2008b), if in the context of a ‘‘state vaccinationprogram.’’ This free of charge for the girls stopped aftertheir 20th birthday.The objective of the program was to make three doses ofthe vaccine available as easily as possible to 11–19-year-old female residents of the state of Geneva (eligible cri-teria) in order to reach the highest possible coverage.The State Medical Office coordinated the Geneva HPVvaccination program. It relied on practitioners in privatepractice (especially pediatricians, gynecologists, internists,and general practitioners), the School Health Service(Service Sante´ de la Jeunesse, SSJ) and a specially estab-lished temporary vaccination structure at the GenevaUniversity Hospital (HUG). Vaccines were made availableto the physicians through the State Medical Office.The promotion of this vaccination program for thepractitioners and the public was jointly implemented by theState Medical Office health, the Geneva University Hos-pital and School Health Service via two sites ofinformation especially developed for this purpose (http://ge.ch/dares/maladies-transmissibles/vaccination_hpv-1030-3374.html and http://www.hpv-hug.ch/). A series of infor-mation brochures was realized and distributed to thehealthcare professionals of the canton and in publicschools. The eligible girls received directly, in their placeof residence, a letter containing their three vouchers ofvaccinations for the first, second, and third shots of vac-cines. They could then choose their dealing doctors or theHUG vaccination structure. In these two cases, thevouchers of vaccinations were transmitted to the StateMedical Office to monitor the program. A system of followup by SMS and letter was set up to remind them of thesecond and third shots of vaccine.Target populationThe target population to be vaccinated was defined by thestate authorities as the 11–19-year-old girls living in thecanton of Geneva. At the beginning of the program inSeptember 2008, approximately 24,000 girls were poten-tially eligible, with a new cohort each year ofapproximately 2,400 girls (data obtained from the statepopulation registry of the Geneva State).Epidemiological monitoringEach service provider transmitted quarterly to the StateMedical Office the anonymous list of the persons who hadreceived their first, second, and third shots. The statisticalanalysis of the collected data was totally anonymous. Thedata were processed through the Te´le´form software andanalyzed to assess the HPV coverage of the target popula-tion. The data collected before June 30, 2011 was includedinto the study. Descriptive statistical methods with the Stata10 software (StataCorp 2007) were used. Confidence inter-vals and inferential statistics were not calculated because thestudied population was considered exhaustive.ResultsThe global coverage rates as of June 30, 2011 for the targetpopulation (1989–1997-born cohorts, 11–19-years old onSeptember 2008, being 14–22-years old on June 2011)were 63.72% for one dose, 63.22% for two doses and61.4% for three doses of the HPV vaccine. These rateswere quite different from one cohort to another. Forexample, for girls born in 1994 or 1995 (16–17-years oldon 30 June 2011), cover rates were 78.5 and 80.3%,respectively for the first dose, 78.2 and 79.5% for seconddose, and 78 and 79.2% for the third dose (Table 1).The contribution to the vaccination program of the threeservice providers varied according to the age of the targetpopulation (Fig. 1). Service providers covered different agegroups. The School Health Service (SSJ) inoculated 70% ofthe 16-year-old ones, 53% of the 15-year-old ones, and lessthan 10% of the 19–22 year-old ones. Medical doctors inprivate practice inoculated 50–60% of the target populationexcept in the 15–16-year-old age group. The HUG (ad hocvaccination center) inoculated around 50% of the older ones(age group 21–22 years) and a much lower proportion(5–15%) of the younger ones (age group 13–16 years).The proportion of eligible girls who did not attend thesecond and/or third dose after receiving the first one wassimilar for all age groups regardless of the service pro-viders, with the exception of the SSJ.DiscussionAdherence is crucial for the effectiveness of a public healthprogram. Effectiveness of an immunization programdepends on high coverage and strong compliance (Rouzierand Giordanella 2010). The results of our study show that630 E. Jeannot et al.123the girls who were eligible at the beginning of the programhave a cover rate of 63.72% for one dose, 65.10% for twodoses, and 61.4% for three doses.The lower rates of vaccination for the older cohorts(1989) might be explained by several elements: they wereless targeted by HPV vaccine promotion campaigns; theyhad limited access to free vaccination: indeed vaccinationwas free of charge only up to the 20th birthday and theymay not have yet a gynecologist and no longer apediatrician.The vaccination patterns according to the service pro-vider show important variations that are most likely due tothe implementation of the program as well as ‘‘consumer’’habits: The School Health Service has inoculated amajority of seventh graders (12–13-year-old ones) becausethis is the main target population. The SSJ had introducedvaccination as early as the school year 2007–2008, thustechnically before the official launch of the vaccinationprogram. Medical doctors in private practice play animportant role, having roughly vaccinated 50% of the tar-get population and up to 65% in certain age groups: thismight reflect the special place that practitioners have asfamily doctors. The HUG inoculated mostly older girls (upto roughly 50% in the 21–22-year-old group): this mightreflect ‘‘an aspiration to some independence’’, since theHUG vaccination unit was less family-oriented than thepractitioners and less school related than the SSJ.There are published data on HPV vaccine coverage inareas where the vaccine was introduced. A study led in NorthCarolina among girls from 9 to 17 years shows cover rates of39.7% for the first dose, 34.6% for the second, and 25.7% forthe third (CDC 2008). Another study from the USA reportsan HPV vaccine coverage of 44.2% for the first dose, 32.3%for the second, and 23.5% for the third among 13–17-year-old girls (Berry-Caban and Buenaventura 2009). An articlefrom England reports coverage rates among 12–13-year-oldgirls for three doses of up to 80% (Canfell 2010). Italy reportscoverage rates for girls born in 1996 and 1997: 80% for thefirst dose, 75% for the second, and more than 60% for thethird. A recent article shows that coverage rates among13–17 years in USA are 53% for three doses (nationalimmunization survey) (Dorell et al. 2011).Success of vaccination programs depends on a numberof elements, including, presence of qualified health experts,availability of the vaccine, its price, the acceptability of thevaccine in the population, a clear promotion strategy,political support, etc. (Smith et al. 2011). The programinitiated in Geneva by the State Medical Office has bene-fited from such a broad approach and gave promisingresults, yet the effort must be kept up. Indeed one of thekey to the success of this program was the participation ofthe School Health Service for effective promotion of thevaccine combined with the implication of private physi-cians and a specially set up vaccination center. Bradinet al. have also demonstrated the importance and theTable 1 Percentage dose one, two, and three for vaccinated girls born between 1989 and 1997 on June 30, 2011 at Geneva, SwitzerlandBirth cohorts Age (years) onJune 30 2011Number ofeligible girls (n)Vaccinated girlsfirst dose (%)Vaccinated girlssecond dose (%)Vaccinated girlsthird dose (%)1989 22 2,282 42.60 41.30 40.901990 21 2,421 52.80 51.90 51.801991 20 2,342 63.50 63.00 62.601992 19 2,256 68.10 68.90 54.501993 18 2,297 75.60 75.30 74.901994 17 2,228 78.50 78.20 78.001995 16 2,307 80.30 79.50 79.201996 15 2,218 79.30 79.00 78.101997 14 2,190 65.90 65.10 64.70Total 1989–1997(target population)22,693 63.72 63.22 61.40Fig. 1 Repartition of vaccination by service provider according toage (years) on June 30, 2011 at Geneva, SwitzerlandHPV vaccination coverage 631123effectiveness of school-based vaccine delivery (Brabinet al. 2008). Coverage data from Australia, where thevaccine policy is also based on school delivery, are veryhigh, which calls for advocating such a strategy (Brother-ton et al. 2008). The possibility for the population tochoose the vaccine inoculators (doctor, HUG, or SSJ)seems to be one of the success key of the immunization’sprogram in the state of Geneva.Data from Switzerland on HPV vaccination programs inthe different cantons will soon be available. At themoment, this study was one of the first. A study from Vaudcanton shows a coverage at 55% for the three doses for14–20 years (Woringer 2010). The Federal Office of thePublic Health is in the process of launching an inventory ofthe HPV vaccination programs implemented in the variouscantons, addressing issues such as the adopted methodol-ogy and the obtained coverage rates: this should give anidea of the HPV vaccination coverage at the country level.Acknowledgments The authors thank Clotilde and Cle´menceDELPECH for they help in the proofreading of this article.Conflict of interest The authors declare that they have no com-peting interest.ReferencesBerry-Caban CS, Buenaventura JB (2009) HPV vaccination coverageamong adolescents aged 9 to 17 years in a United States militarytreatment facility. Int J Adolesc Med Health 21(4):567–570Brabin L, Roberts SA, Stretch R, Baxter D, Chambers G, KitchenerH, McCann R (2008) Uptake of first two doses of humanpapillomavirus vaccine by adolescent schoolgirls in Manchester:prospective cohort study. BMJ 336(7652):1056–1058Brotherton JM, Deeks SL, Campbell-Lloyd S, Misrachi A, Passaris I,Peterson K, Pitcher H, Scully M, Watson M, Webby R (2008)Interim estimates of human papillomavirus vaccination coveragein the school-based program in Australia. Commun Dis Intell32(4):457–461Canfell K (2010) Monitoring HPV vaccination programmes. BMJ340:c1666Center of Disease and Control (2008) StatBite: HPV vaccinationamong U.S. girls aged 13-17 years in 2007. J Natl Cancer Inst100(22):1570Dorell CG, Yankey D, Santibanez TA, Markowitz LE (2011) Humanpapillomavirus vaccination series initiation and completion,2008–2009. Pediatrics 128(5):830–839. doi:10.1542/peds.2011-0950Office Fede´rale de la Sante´ Publique (2008a) Recommandations devaccination contre les papillomavirus humains (HPV)Office Fede´rale de la Sante´ Publique (2008b) Vaccination contre le cancerdu col de l’ute´rus - but des programmes cantonaux de vaccinationRegistre des tumeurs (2009) Le cancer a` GeneveRouzier R, Giordanella JP (2010) Coverage and compliance ofHuman Papilloma Virus vaccines in Paris: demonstration of lowcompliance with non-school-based approaches. J Adolesc Health47(3):237–241Simoens C, Sabbe M, Van DP, Beutels P, Arbyn M (2009)Introduction of human papillomavirus (HPV) vaccination inBelgium, 2007–2008. EuroSurveill 14(46)Smith LM, Brassard P, Kwong JC, Deeks SL, Ellis AK, Levesque LE(2011) Factors associated with initiation and completion of thequadrivalent human papillomavirus vaccine series in an ontariocohort of grade 8 girls. BMC Public Health 11:645. doi:10.1186/1471-2458-11-645StataCorp (2007) Stata 10Wong CA, Berkowitz Z, Dorell CG, Anhang Price R, Lee J, SaraiyaM (2011) Human papillomavirus vaccine uptake among 9- to17-year-old girls: National Health Interview Survey, 2008.Cancer 117(24):5612–5620. doi:10.1002/cncr.26246Woringer V (2010) Etude de la couverture vaccinale dans le canton deVaud apre`s la premie`re campagne de vaccination contre lepapillomavirus (HPV), anne´e scolaire 2008–2009World Health Organisation (2005) Report of the consultation onhuman papillomavirus vaccines632 E. Jeannot et al.123

HPV vaccination coverage within 3years of program launching (2008-2011) at Geneva State, Switzerland

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HPV vaccination coverage within 3years of program launching (2008-2011) at Geneva State, Switzerland

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