Effectiveness of a School-Based Human Papillomavirus Vaccine Program for Increasing Vaccine Uptake in an Underserved Area

Background: The annual U.S. medical cost of Human Papillomavirus (HPV)-associated disease (e.g., cervical, oropharyngeal, vulvar, vaginal, penile, anal cancers and pre-cancers) is ~$8 billion. More than 80% of this cost is attributed to cervical cancer. Increases in HPV vaccination rates will reduce this cost by decreasing the morbidity/mortality of HPV-associated diseases especially cervical cancer. HPV vaccination is recommended for boys/girls at age 11-12 and can be given as early as 9 with catch-up doses for those aged 13-26. Recently, the FDA approved this vaccine for adults aged 45 years and younger. The U.S. HPV vaccine completion rates remain low (49.5% for girls and 37.5% for boys aged 13-17 years). HPV-associated diseases disproportionately affect individuals in low-income, rural and medically underserved areas such as the Rio Grande Valley (RGV) in Texas where screening rates for HPV-associated diseases and HPV vaccine uptake are low. Women in RGV are more likely to be Hispanic, and have a 30% higher cervical cancer incidence and mortality rate compared with the rest of Texas. Strategies to reduce disparities in HPV vaccine uptake are crucial for reducing morbidity/mortality of HPV-associated disease in resource-poor areas like the RGV. One strategy to deliver HPV vaccines is the use of school-based settings, which has shown success in countries like the U.K./Australia. Schools have the highest reach to adolescents and have demonstrated success in providing other vaccines.

Objective: Compare the effectiveness of HPV-related education versus HPV-related education plus school-based vaccination in increasing HPV vaccine initiation and completion rates among middle school students.

Method: This prospective study was conducted in a middle school district of an undeserved Texas county (Starr County in RGV). Two middle schools received the HPV education-only intervention, while one middle school received HPV education plus school-based vaccination (“intervention-plus”). The HPV education consisted of HPV-related educational sessions delivered to parents/guardians, school staff, local primary care and pediatric providers and the overall community. In addition to educational sessions, free HPV vaccinations were provided at one school. Vaccine uptake rates were compared between the education-only schools and the intervention-plus school. Proportions were compared using chi-squared tests and means using t-tests. Logistic regressions compared the likelihood of those students who newly initiated/completed vaccination during our program between the two groups.

Results: The baseline HPV-vaccine initiation (20.00% vs. 18.97%, p<0.001) and completion (8.70% vs. 14.56%, p<0.001) rates at the intervention-plus school were lower than education-only schools. After 20 months of intervention, the initiation (53.67% vs. 41.56%, p<0.001) and completion (28.36% vs. 20.53%, p<0.001) rates were higher at the intervention-plus school. The logistic regressions revealed that students from the intervention-plus school were almost 4-times more likely to both newly initiate (odds ratio [OR]=3.63, 95% CI=2.94-4.50) and complete (OR=3.82, 95% CI=2.90-5.03) the HPV vaccination than those from the education-only schools after adjusting for gender and age.

Conclusion: Our program provides evidence on the feasibility of a school-based HPV vaccination program. We demonstrate that HPV vaccinations in non- traditional settings (i.e., school-based vaccination programs) are effective and can substantially boost vaccine uptake in under-served areas.