Vaccine Programme Stakeholder Perspectives on a Hypothetical Single-Dose Human Papillomavirus (HPV) Vaccine Schedule in Low and Middle-Income Countries

The World Health Organization (WHO) recommends a 2-dose human papillomavirus (HPV) vaccine schedule for girls aged 9-14 years. As randomised controlled trials assessing the immunogenicity and efficacy of a 1-dose schedule are ongoing, the researchers interviewed immunisation programme managers and advisors in low- and middle-income countries (LMICs) about a hypothetical, future reduction in the HPV vaccine schedule. In an effort to understand the potential policy implications of changing schedules, the researchers sought, for example, to identify the motivators for and barriers to changing the existing HPV vaccine schedule and what further information might be needed to inform a policy change.

Thirty stakeholders from 18 countries provided written informed consent for interview between August and December 2017; more than one interview was conducted in 61% of countries. Interviews were conducted with 9 Expanded Program on Immunization (EPI) managers, 10 National Immunisation Technical Advisory Group (NITAG) members, 5 WHO/national immunisation managers, and 6 other individuals.

All of the 30 key informants (KIs) interviewed had a good comprehension of the vaccine's effectiveness; 27 KIs (90%) representing all 18 countries thought that a future, hypothetical schedule change to a single-dose HPV vaccine schedule would be supported by key stakeholders within their country.

Eight KIs from 6 countries cited concerns around gaining community or individual acceptance of a single-dose schedule. KIs referred to the potential for individuals or communities to question whether 1 dose would be sufficient to provide adequate protection, given the mobilisation and communication to date on the importance of receiving 2 or 3 doses. Seven KIs from 6 countries cited potential acceptability issues among health care workers (HCWs) as a potential barrier to a 1-dose HPV vaccine programme, given that their training to date has specified 2 or 3 doses. Five KIs stated that sourcing the resources needed for the retraining of HCWs and remobilisation of the community would be a challenge if no extra support was provided.

KIs from 9 countries thought that a WHO position paper or a WHO recommendation would be required before policymakers would consider a change to a 1-dose HPV schedule. KIs from 8 countries stated that evidence on the efficacy of 1-dose of HPV vaccine against HPV infection and/or clinical endpoints compared to 2 or 3 doses would be important in the decision-making process around recommending a change in schedule. All KIs from all 18 countries stated at least 1 source of information they perceived would be required for the decision-making process around a future, hypothetical HPV vaccine schedule change. Often, multiple sources of information were listed.

There were concerns that the change in policy could fuel negative media coverage of the national immunisation programme. KIs from 3 countries mentioned the potential for information around a further schedule change to be used negatively by girls who had already been vaccinated and who were affected by adverse events following immunisation (AEFIs), by anti-vaccine groups, or by the media. One KI explained that a formal recommendation from the WHO would be useful to dispel any resistance propagated by anti-vaccine groups.

KIs from 3 of the 18 countries specifically stated they would want to hear lessons from other countries that had introduced a single dose schedule - i.e., that they would not want to be the first to implement.

In conclusion, a number of KIs stressed that, although a single dose schedule might alleviate some of the logistical and financial challenges of HPV vaccine delivery, there remained a need for strong political will, social mobilisation, and HCW training to ensure programme success and longevity.