Adolescent and young adult HPV vaccination in Australia: Achievements
Suzanne M. Garlanda,b,c,⁎, S. Rachel Skinnerd, Julia M.L. Brothertond,e
aDepartment of Microbiology and Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia
bDepartment of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
cMurdoch Childrens Research Institute, Parkville, Victoria, Australia
dSydney University Discipline of Paediatrics and Child Health, Children's Hospital Westmead, Sydney, Australia
eVictorian Cytology Service Registries, East Melbourne, Victoria, Australia
a b s t r a c t a r t i c l ei n f o
Australia commenced an ongoing school based government funded human papillomaviruses (HPV) (cervical
cancer prevention) vaccination program in April 2007 for adolescent females aged 12–13 years. In addition,
up to December 31, 2009, a catch-up program for young females 13–26 years of age was offered: a school-
based vaccination program was used to offer HPV vaccine to girls enrolled in school (14–17 years), and
general practitioners or other community health provider offered vaccine to young women aged 18–26 years.
To date, only the quadrivalent vaccine (HPV 6/11/16/18) has been utilized in the funded program. Acceptance
of the vaccine ishigh with coverage of3 doses ofthe HPV vaccine in the school agecohort around 70%, andjust
over 30% in the older age cohort. Since the vaccination program was initiated, a reduction in new cases of
genital warts of 73% among vaccine eligible age females has been evidenced in STI clinics across Australia. A
reduction of 44% of new cases in young males (not a part of the free program) was also documented during
this same time period, suggesting significant herd immunity. Similarly, in the state of Victoria, a small but
significant decrease in high grade abnormalities in Pap screening findings has been reported in young
womenb18 years for the period 2007–9, as compared to pre-vaccination. Challenges for the future include
how we can sustain and improve HPV vaccination coverage in young Australian women, while maintaining
cervical cancer screening participation and reviewing cervical cancer screening methods.
© 2011 Published by Elsevier Inc.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Background: population and health care delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Childhood vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adolescent vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HPV-associated morbidity in Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HPV vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vaccine coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Knowledge of and attitudes to HPV and related diseases and HPV vaccination in Australian young people . . . . . . . . . . . . . . . . . . . .
The media and adverse events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Impact of the vaccination program on disease incidence in Australia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Challenges: looking towards the future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest statements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
As the first country to introduce a fully funded national human
papillomavirus (HPV) vaccination program, and with a history of
previous successful adolescent vaccination programs, Australia's
Preventive Medicine 53 (2011) S29–S35
⁎ Corresponding author at: Department of Microbiology and Infectious Diseases, The
Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia. Fax: +61 3
E-mail address: Suzanne.Garland@thewomens.org.au (S.M. Garland).
0091-7435/$ – see front matter © 2011 Published by Elsevier Inc.
Contents lists available at SciVerse ScienceDirect
journal homepage: www.elsevier.com/locate/ypmed
experience in the first few years of the program may be of assistance
to other countries planning similar programs. In this article we
describe Australia's health care and immunization delivery systems,
HPV burden, HPV vaccination program, coverage achieved, and
community knowledge about HPV and evidence of impact to date,
as well as ongoing challenges.
Background: population and health care delivery
Australia has an estimated population of just over 22.3 million
(ABS, 2010). Despite its large size geographically, it is only the 50th
most populous country in the world (urban population of 89%) as its
population is concentrated predominantly in coastal areas. It is a
multicultural society with 27% of the total population in mid 2010
being born outside Australia (A.B.S., 2011). Most of Australia's
population is of European descent, with 8% being of Asian descent
and the indigenous population estimated to comprise 2.5%. Australia
has an ageing population with a median age of 36.9 years. Young
people aged 10–24 years make up 21% of the population. In 2010,
females aged 10–14 years represented 3% of the entire population.
The national government provides a universal national health
insurance system (Medicare), which provides access to health care for
there is also a private health care sector. All recommended childhood
vaccines included in Australia's National Immunisation Program
(Australian et al., 2011) are funded by the national government, with
delivery programs largely funded and coordinated by the 8 State and
Territory governments. Vaccination is conducted largely by general
practitioners (GPs) through their clinical practice, or through local
government immunizing nurses, community health service providers,
including Aboriginal Health Care workers and local councils. School
based immunization teams, coordinated through local government or
regional health authorities, provide the majority of vaccines to the
adolescent age group. There is some variation as to how this is
implemented in each State.
In general, there is good acceptance of vaccination in Australia and
coverage of recommended childhood vaccines is over 90% for two year
old children, and around 80% for five year old children (Hull et al.,
2010a). Australia's childhood vaccination program is supported by a
national childhood immunization register which issues reminders to
parents and general practitioners of recommended vaccines, financial
incentives for parents and general practitioners to complete vaccina-
tions and legislation which requires that parents provide a record of
their child's immunization status at primary school entry. While
vaccination is not compulsory in Australia, an immunization record is
required in primary school so that unvaccinated children can be
excluded from school in the event of a vaccine preventable disease
outbreak. Adverse events following immunization are monitored
through passive surveillance. Within each state and territory, there
are various levels of enhanced safety monitoring: in Victoria for
example, the State government established a new service SAEFVIC
(surveillance of adverse events following vaccination in the communi-
ty) in April 2007. This has been pertinent in following up and defining
rates of potential adverse events from the cervical cancer vaccine
program (Crawford et al., 2011).
Australia has a long tradition of voluntary school based vaccination
for adolescents, which goes back even earlier than the 1970s when
monovalent rubella vaccine was offered through school programs to
young adolescent girls in most states and territories. However, school-
based vaccination has not been consistently utilized in all jurisdictions.
For example, when the 3-dose pediatric formulation of hepatitis B virus
(HBV) vaccine was recommended in 1998 for all young adolescents in
Australia, some states relied on delivery through primary health care
providers (mainly general practitioners [GPs]). The difference in
coverage for this vaccine across states with different delivery strategies
systems differences. In states relying on GP delivery of vaccine, lessthan
30% of adolescents had received one or more doses of the HBV vaccine
(Correll et al., 2003; Malcolm et al., 2000), compared with over 80% of
adolescents in states with a school program (Skinner et al., 2000). A
randomized controlled trial in New South Wales of school based versus
GP delivery demonstrated a 10 fold higher HBV vaccine completion rate
in adolescents offered school based delivery (Heron et al., 2003). High
elsewhere worldwide (British Columbia Centre for Disease Control,
2009; Skinner and Cooper Robbins, 2010). All states and territories of
Australia have now implemented school based delivery of all recom-
mended vaccines for the adolescent age group. Queensland introduced
school based vaccination in 2007 and an improvement from 30% to 60%
in first dose HBV vaccinecoverage in adolescents was noted in that year
(Queensland Government, 2010).
Current recommended vaccines for the young adolescent age
group in Australia (10–17 years) include 2-dose hepatitis B adult
formulation vaccine, varicella vaccine where no history of clinical
varicella exists, a trivalent diptheria tetanus and acellular pertussis
vaccine booster (dTpa), and 3 doses of human papillomavirus (HPV)
vaccine (girls only). Many states offer the vaccines in one school year
level (usually year 7 or year 8 which corresponds to 11–14 years), and
adolescents may receive more than one vaccine on 1 day. Recom-
mended vaccines in this age group may change, with new vaccines
introduced and others (such as HBV) dropping off as near fully
vaccinated young childhood cohorts reach adolescent age.
Each state and territory have their own specific protocol for
consent forms and immunization procedures, information materials,
and structure for organizing immunization teams to visit schools and
provide vaccinations to adolescents. In general, consent forms and
information brochures are taken home to parents/guardians by
students and the signed consent forms then returned to the school
and collected by the teacher. On the vaccination day, students with a
parental signature indicating consent will receive the vaccine to
which this applies. Unlike for parents, there is generally no organized
provision of informational materials specifically for adolescents; and
teachers and schools are not required to provide education on
vaccines offered in the school program. Traditionally, adolescent
vaccination programs have been the responsibility of the health
department in each state, permitted by the education sector to take
place in schools on a good will basis; as such there is no school
provision of education as part of the immunization service.
school age to young adults in Australia. Vaccination coverage of this
date. For example, in 2001, a young adult measles–mumps–rubella
campaign was undertaken to vaccinate young Australians aged 18–
identified as a target age group with the largest gap in population
immunity to measles. No reduction in measles susceptibility was
demonstrated in a sero-survey evaluation (Gidding et al., 2007).
In Australia there are no specific GP preventive health care visits
recommended for adolescents and young adults, unlike for example,
preventive visits recommended though the GAPS program in the USA
(Health,1997). Compared to other age groups, young people aged 15–
25 years have the lowest proportion of face-to-face time spent with
GPs in a given year in Australia. Females in the 20–25 year age group
have an average of 4.8 visits to GPs in a year, while males have less
than half this number of visits (Charles et al., 2009; Booth et al., 2008).
Apart from mass campaigns promoting general practitioner delivery
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35
ofvaccines totheyoungadultage group,otherstrategiesfor achieving
high coverage in this age group have not been tried, perhaps because
vaccines are only infrequently recommended for routine administra-
tion to this age group. Legislation mandating vaccination completion
at high school entry has been particularly effective at promoting high
coverage of adolescent recommended vaccines in the US (Averhoff et
al., 2004; Jacobs and Meyerhoff, 2004). It has been well described that
vaccines which are not mandatory have much lower coverage than
vaccines which are mandated (Skinner and Cooper Robbins, 2010;
Skinner and Nolan, 2001). While legislation linked to school is clearly
effective for achieving high coverage of vaccine in adolescents, and
possibly college entry legislation for young adults too, legislation in
these age groups has not been considered in Australia thus far. Given
the increasing proportion of the young adult population enroling in
University or other tertiary education institutions, it may be a
worthwhile consideration into the future. Reminders and financial
incentives may be another approach worth trialing; however,
reminders and incentives operated at a population level would most
likely need to be facilitated by a vaccination register (such as the
ACIR) linked to universal health card card numbers (Medicare) as
occurs with incentives and reminders for young childhood vaccines
and now the National HPV Program Vaccine Register (HPV Vaccine
Register) in Australia.
HPV-associated morbidity in Australia
As in other Western countries, HPV infection is very common in
Australia. A large pre-vaccination study of cervical HPV prevalence in
Australian women found a wide range of types detected, multiple
infections common, peak incidence in the years following sexual debut
(median of 16 years in Australia) and that HPV16 was the most
commonly detected type (Garland et al., in press). Data collected in
ofcervical cancersand highgradedysplasiasrespectively(Stevenset al.,
2006). Australia also has a highly successful publically funded national
cervical screening program for the prevention of cervical cancer. With a
relatively early recommended starting age of 18 years or 2 years after
sexual debut (whichever is later), and a two year interval, peak rates of
high grade cervical abnormality detection occur in 20–24 year olds in
Australia, with the program screening about 1.75 million women a year
and detecting ~90,000 low grade abnormalities and ~15,000 high grade
abnormalities (National Health and Medical Research Council, 2006).
Prior to vaccination, genital warts (caused predominantly by HPV6
STI clinics across Australia (Brotherton et al., 2009), peaking in those
around25 yearsofage,withthemedianageforwomenbeing23 years
a large health and cost burden on Australians (Pirotta et al., 2010) as
well as carrying a significant psychosocial burden for young people
(Pirotta et al., 2009b).
After expert consideration and on the basis of acceptable cost
effectiveness (Nolan, 2010), in April 2007, Australia commenced the
most comprehensive government funded national HPV vaccination
2009 for all women aged 12 to 26 years in Australia (Garland et al.,
2008). Girls still at school (ages 12–17) were vaccinated in school
vaccine through their GP or other community immunization provider.
School enrolment attendance rates in Australia are high, with 98.5% of
2010). Women aged 18–26 were able to access the vaccine through
their GP or other providers such as university health services, women's
health centers, Family Planning services, councils or Aboriginal Medical
and funded social marketing campaign primarily targeting mothers and
daughters (‘at last there's some good news about cancer’) and a
HPV vaccine in Australia (‘protect yourself against cervical cancer’ “I
did”). The company also offered a cell/mobile telephone text reminder
their second and third vaccine doses were due. Federal government
provided GPs with materials explaining the rationale and details of the
program. A survey of GPs in 2008 found high levels of support for the
in cervical screening post vaccination (Brotherton et al., 2010).
HPV vaccine continues to be offered to all girls in the first year of
high school or last year of primary school (years 7 or 8 depending on
the jurisdiction, which corresponds to ages 12–13 years) as an
ongoing school based program alongside other vaccines offered in
the school vaccination program (Australian Government Department
of Health and Ageing, 2011a). HPV vaccine has a separate parent
information sheet and consent form. Parents provide written consent
for vaccination of the girls and consent for notification of their
adolescent's HPV vaccination to the HPV vaccine register and longer
term linkage to state cervical cytology and cancer registers. It is
theoretically possible for a girl to be vaccinated against her parents'
wishes outside of the school program if a GP is able to determine
competency to provide consent. Where a parent provides consent for
vaccination, the adolescent has the right of refusal.
School based vaccination is a complex initiative, with up to a hundred
or so students vaccinated in one school on 1 day. Processes which
promote and hinder vaccination consent and completion have not been
well evaluated in Australia, or elsewhere. Logistical factors have been
identified as potentially important to program success. A systematic
by the authors (currently unpublished) found that logistical factors have
vaccinated and appropriate management of adolescent anxiety (Cooper
Robbins et al.,2010b; Bernard et al.,2011). Educationofteachers,parents
school based vaccination program success. While ideally, adolescents
should participate in an informed assent process (or consent if capable),
be difficult to achieve in the setting of school based vaccination (Bernard
et al.,2011;CooperRobbins et al.,2010a,2010c). Thecomplex logisticsof
delivering mass school based vaccination, where consent for the
vaccination is provided days or weeks before the actual vaccination day
at the school, and where many adolescents must be vaccinated in a short
time frame, challenge the feasibility of provider assessment of individual
adolescent assent and/or cognitive maturity to provide consent to
vaccination (Cooper Robbins et al., 2010b). In the UK however, provision
exists for assessment of Gillick competence (mature minor status) in
adolescents under 16 years to provide consent to vaccination in school
programs, where that may be appropriate (Department of Health, 2007),
provide their own consent to vaccination.
Although the two available HPV vaccines are licensed in many
countries worldwide (123 and 114 for the quadrivalent and bivalent
vaccines respectively), because of current high costs, this often equates
only to use in private markets. To have a sustained population level
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35
impact on disease, high coverage of the target population is required.
This is most likely achieved when the vaccine is provided at no or low
cost to the individual and preferably when incorporated into routine
national vaccination programs with demonstrated success in the target
vaccines recommended in the adolescent age group has not been
achieved. This may be because there have not previously been vaccines
implemented. In the case of the USA, legislation mandating HPV
vaccination prior to high school entry has not been successfully
implemented for a variety of reasons; thus coverage is likely to be
lower than for other recommended vaccines such as hepatitis B which
had been mandated for school entry in the majority of states (Skinner
and Cooper Robbins, 2010).
In Australia, monitoring of HPV vaccination coverage is assisted by
a National HPV Vaccination Program Register (NHVPR). The NHVPR
was established through legislation in order to collect data about HPV
vaccines administered to females across all settings and to assist with
monitoring the program's impact through eventual data linkage to
Pap cytology test and cervical cancer registers (Gertig et al., 2011).
The legislation allows for vaccination information to be forwarded to
the NHVPR unless the woman vaccinated (or parent in the case of
vaccinated school girls) objects (opts off). While transfer of the HPV
vaccine data from States' school programs to the NHVPR is complete
(apart from any girls who have opted off), this notification process is
not compulsory for GPs: thus vaccinations administered to women
over 18 in the catch up program may well have been under-notified.
To promote notification, GPs were paid $6 per dose notified to the
NHVPR as an incentive payment, similar to the notification incentive
provided to GPs for notification of child vaccines to the Australian
Childhood Immunization Register.
Coverage estimates forthe routine and catch up cohortsfrom 2007–
2009 were recently released (Australian Government Department of
Health and Ageing, 2011b). Moderately high coverage was achieved
across the school based cohorts (three dose coverage 73%/72%/66% for
12–13, 14–15 and 16–17 year olds respectively. Coverage of the first
dosewasat least 10% higher (83%/84%/81%). For the state of New South
Wales, uptake for 3 doses of HPV vaccine was similar to the uptake
regime. A trend to lower coverage in older school age cohorts is also
consistent with other vaccines recommended in this age group in
Australia (Ward et al., 2010). The NHVPR estimates reflect vaccines
administered through schools and GPs and use denominator data
than school enrolments. The register estimates thus include the small
proportion of adolescents who are not enrolled in school (and not
offered the vaccine through the school program), but will also capture
adolescents who may have received vaccine doses through their GP.
Thus it should reflect actual coverage in the population. In young
women beyond school age, under notification to the register may have
reduced estimates of one-dose coverage (64% and 52%) and three-dose
coverage (38% for 18–19 year olds and 32% for 20–26 year olds) (Gertig
et al., 2011). Independent estimates of coverage in young women in
clinical and GP populations, and the coverage estimates from those
jurisdictions with central notification of vaccination data from general
n.d.; Brotherton et al., in press), personal communication S.M. Garland].
Knowledge of and attitudes to HPV and related diseases and HPV
vaccination in Australian young people
Two studies of population based computer assisted telephone
surveys (CATIs) of HPV knowledge and awareness in Victorian
women and South Australian adults were published in early 2007
(Pitts et al., 2007). These studies were undertaken before the mass
one of the discoverers of the VLP technology which underpinned the
development of HPV vaccine formulations and their unique immune
mechanisms. Marshall et al. (Marshall et al., 2007) found very poor
awareness of HPV as the cause of cervical cancer or other disease
outcomes, while Pitts et al. (Pitts et al., 2007) found that 51% of
respondent women had heard of HPV, and half of these women
identified that HPV was associated with cervical cancer. Qualitative
research with young adults during this time found reasonable
awareness and knowledge of some STIs, including genital warts, but
very limited awareness of the HPV virus as a causative agent for genital
warts or cervical cancer (McClelland and Liamputtong, 2006). Another
low awareness of the link between HPV and cervical cancer (Giles and
Garland, 2006). More recently however, a national CATI survey of
HPV(Pitts etal.,2010).Ofthese, 66%knewofthelinkbetweenHPVand
cervical cancer and 45% between HPV and genital warts. Women in the
middle adult years (26–45 years) had the highest levels of knowledge,
with men and younger people with lower levels of knowledge, In a
et al., 2010), there was lower awareness of HPV (43% of females, 19% of
males), its association with cervical cancer (35% females, 11% of males),
genital warts (14% females, 5% males)and its sexual transmission (45%
females and 27% of males), than in adults. The response category most
often reported by both males and females was ‘Don't Know’ for every
question apart from HPV awareness. The higher knowledge among
females was mostly accounted for by HPV vaccination status, (86%
females reported being vaccinated, 3% unsure; 5% males reported being
vaccinated, 11% unsure). It is noteworthy that this survey design
don't know), allowing higher percentage correct by chance, compared
to the CATI branched algorithm design used in the adult surveys, and
that most of the female respondents had actually received the vaccine
through the national HPV vaccination program earlier in the year they
were surveyed and yet their knowledge was still poor.
It is clear that awareness of HPV, understanding of HPV's sexually
cancer have increased substantially among Australian women (Pitts et
less well known, such as the link between HPV and genital warts, and
that males can also catch HPV; this is likely a reflection of the social
marketing campaign with messages focusing on cervical cancer and
with genital warts were also noticeably absent from Australian
newspapers: none of the newspaper articles published during the
introduction of the vaccination program,and through thecompletion of
vaccine,” as US media has sometimes termed HPV vaccination (Cooper
documented that HPV was sexually transmitted in 23% of the articles
reported this in77% of theirsample (Kelly etal., 2009).Theemphasis on
cervical cancer prevention in Australian newspapers was clearly
prominent, with 60% of articles referring to the HPV vaccine as the
“cervical cancer vaccine” (Cooper Robbins et al., in press).
Of additional interest in these Australian studies was the low
proportion of parents who were concerned that HPV vaccination may
promote sexual behavior in teenagers (Pitts et al., 2007; Marshall et
al., 2007). One study also found that promoting the vaccine's effect in
the prevention of genital warts was not stigmatizing, and that young
women would prefer a vaccine which prevented both cervical cancer
and genital warts than cervical cancer alone (Juraskova et al., n.d.). Of
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35
some concern remains the lack of knowledge and understanding of
HPV and HPV vaccination among adolescents who are the main target
of population vaccination initiatives. In a qualitative study conducted
in Sydney secondary schools, some parents reported feeling uncom-
fortable explaining to their adolescent why they needed the vaccine.
This was related partly to a lack of knowledge in the parent and partly
to embarrassment in discussing a disease which is sexually transmit-
ted (Cooper Robbins et al., 2010c).
The media and adverse events
While initial media reports (television, newspaper, magazines etc.)
were very positive when providing information to the general public
about the HPV vaccination program, an incident of a potential vaccine
one school in Melbourne, 720 girls aged 12–17 years received the HPV
vaccine, with 26 presenting within 2 hours to sick bay with dizziness,
syncope and/or neurological symptoms. Several were assessed in a
hospital setting. The incident was investigated by the specialist unit for
investigating reports of adverse events following immunization in
a psychogenic response to mass vaccination in a school setting (Buttery
Minister for Health rapidly stated ongoing confidence in the vaccine
program, and the program was not interrupted.
An analysis of newspaper articles spanning the introduction of the
HPV vaccination program to the end of the catch-up program
(October 2006-December 2009), reported that the top three concerns
were: safety and efficacy of vaccine (discussed in 38.9% of articles),
the need for women to continue Pap screening (19.8%), and the
availability of HPV vaccination for males (14.5%) (Cooper Robbins et
al., in press). Media representations of safety concerns peaked
between May and June 2007 during the incident of mass psychogenic
illness in Melbourne. A second peak occurred between June and
September 2009, when a publication in JAMA (Slade et al., 2009)
reported that 12,424 recipients suffered mild to serious side effects
after receiving Gardasil (Cooper Robbins et al., 2010a).
syncope and syncopal seizures were noted at rates of 7.8/100,000 and
2.6/100,000 doses of the quadrivalent HPV vaccine distributed,
respectively. These rates are the same as those reported internationally
clinical review allowed clarification of the diagnosis and management,
with safe administration of further doses under the supervision for the
girls who had experienced the adverse event (Crawford et al., 2011).
of myths regarding spurious side-effects can occur quickly, with
potentially adverse consequences such as public outcry and a sudden
consequent drop in coverage has been documented with the MMR
vaccine in the UK (Health Protection Report, 2010) and a school based
hepatitis B vaccine program in France (Monteyne and Andre, 2000). All
school based vaccination protocols in Australia provide guidance as to
how to reduce the risk of such occurrences.
Impact of the vaccination program on disease incidence in
Australia has already seen the impact of the HPV vaccination
program on HPV 6/11 related infections, through a rapid decline in
genital wart presentations at sentinel sexual health clinics (Donovan et
al., 2010). This has been not only in women less than 27 years of age
not part of the free vaccination schedule and only a few percent of the
eligible age group are vaccinated), an indication of herd immunity due
rate continues to go down: with reports of a decline of 73% for young
women and 44% for young men by the end of 2010 (Donovan et al.,
Cervical Cytology Registry, a modest but significant decrease in high
grade abnormalities wasdemonstrated in those women agedb18 years
between 2007 and 2009 when the HPV vaccination program was
delivered, and compared with the pre-vaccination period. It should be
noted that recommendations in Australia for commencing Pap
screening is at 18 years of age or 2 years after sexual debut, whichever
reduction is indeed due to vaccination, data linkage between the
vaccination register and Paptest registers will in the nearfuturebeable
to demonstrate whether such reductions are indeed occurring among
the vaccinated women.
Challenges: looking towards the future
Although the largely successful catch up program has been
completed, challenges remain. A greater reduction in HPV disease
burden would ultimately be achieved with higher population
coverage; if 3-dose vaccination coverage were increased from 67%
to 90%, models predict long term reduction in incident infection will
be increased from 76% to 95%. (22) Data from England and Scotland
indicate that higher coverage is possible in HPV school based
vaccination programs (Sheridan et al., 2011; NHS National Services
Scotland, 2011). Thus it would be prudent for Australia's different
jurisdictions to evaluate school program processes to determine how
coverage may be optimized. Given the higher rates of cervical cancer
incidence and mortality among disadvantaged women and among
Aboriginal and Torres Strait Islander women in Australia, it is also
importantto examine the extent to which vulnerable sub-populations
are reached by the vaccination program.
There can also be challenges around public perceptions of the
appropriateness andsafety of vaccinatinglarge numbersof childrenin
a school setting. To ensure the on-going success of school vaccination
programs in Australia, solid support from the public is necessary. In
particular, we should be considering the benefits of promoting greater
understanding in the general public about vaccination including HPV
vaccination. Due as much to traditional separation of roles of health
and education sectors regarding immunization, as the logistical
challenge of vaccine delivery en masse in a school program,
adolescents miss the opportunity to ask questions and be given
information. Informed adolescents are more likely to understand the
limitations of vaccination (such as the future imperative to participate
in cervical screening), and experience less anxiety on the vaccination
day. Education for young people should be designed in a way that is
appealing to young people and readily accessible to them when they
wish to ask questions (such as when they are waiting in line for the
vaccine at school). Education must also be easy to implement and not
create an additional workload for schools and teachers (Cooper
Robbins et al., 2010b).
In Australia, as in many similar countries, participation rates in
cervical screening among young women have been falling (Lancucki
et al., 2010). Data linkage is therefore important not only to monitor
the impact of the vaccine on cervical disease but also to monitor
participation rates among vaccinated women. Australia may also be
one of the first countries to face the prospect of a previously successful
cytology screening based prevention program becoming ineffective
due to declining lesion prevalence in the target population. It is likely
that the age at which screening commences in Australia will be able to
be safely raised and the interval extended (Creighton et al., 2010).
Newer technologies for screening, such as primary HPV DNA testing,
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35
are promising alternatives, possibly with incorporation of cytology
and/orother molecular markersfor triage of HPVDNApositivewomen
(Tota et al., 2010). Adoption of liquid based cytology in Australia
would also greatly facilitate surveillance of HPV types post
Conflict of interest statements
JMLB is an investigator on an Australian Research Council Linkage Grant, for which CSL
Biotherapies is a partner organisation. JMLB was an investigator on a national HPV
prevalence study that received partial, equal and unrestricted funding from CSL
Biotherapies and GlaxoSmithKline.
JSMG has received advisory board fees and grant support from Commonwealth
Serum Laboratories and GlaxoSmithKline, and lecture and consultancy fees from
Merck and Co. SMG reports having previously owned stock in Commonwealth Serum
Laboratories. SMG has received grant support through her institution from Merck
and Co and GlaxoSmithKline [GSK] to do clinical trials for HPV/cervical cancer
A.B.S., A.B.o.S. 3412.0 - Migration, Australia, 2009–10 Quality Declaration Latest ISSUE
Released at 11:30 AM (CANBERRA TIME) 16/06/2011 [cited.
ABS, 3201.0, and Population by Age and Sex, Australian States and TerritoriesJun 2010
[cited; Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3201.
Agius, P.A., et al., 2010. Human papillomavirus and cervical cancer: Gardasil vaccination
status and knowledge amongst a nationally representative sample of Australian
secondary school students. Vaccine 28 (27), 4416–4422.
Australian Government Department of Health and Ageing, 2011a. Immunise Australia
Program[cited July 14 2011]; Available from: www.immunise.health.gov.au.
Australian Government Department of Health and Ageing, 2011b. Immunise Australia
Program: Human Papillomavirus (HPV) vaccination program. 2011 4-April 2011
[cited 25-11-2011]; Available from: http://www.immunise.health.gov.au/internet/
Australian, et al. Immunise Australia Program. 30 May 2011 [cited July 14 2011];
Available from: www.immunise.health.gov.au.
Averhoff, F., et al., 2004. A middle school immunization law rapidly and substantially
increases immunization coverage among adolescents. Am. J. Public Health 94 (6),
Bernard, D.M., et al., 2011. The domino effect: adolescent girls' response to human
papillomavirus vaccination. Med. J. Aust. 194 (6), 297–300.
Booth, M.L., Knox, S., Kang, M., 2008. Encounters between adolescents and general
practice in Australia. J. Paediatr. Child Health 44 (12), 699–705.
British Columbia Centre for Disease Control, 2009. Immunisation in British Columbia,
Brotherton, J.M.L., et al., in press. Catching up with the catch-up: HPV vaccination
coverage data for Australian women aged 18–26 years from the National HPV
Vaccination Program Register. Communicable Diseases Intelligence.
women prior to the national vaccination program. Sex. Health 6, 178–184.
Brotherton, J.M.L., et al., 2010. National survey of the general practitioner's experience
of delivering the National Human Papillomavirus Vaccination Program. Sex. Health
Brotherton, J.M.L., et al., 2011. Early effect of the HPV vaccination programme on cervical
abnormalities in Victoria, Australia: an ecological study. Lancet 377, 2085–2092.
Buttery, J.P., et al., 2008. Mass psychogenic response to human papillomavirus
vaccination. Med. J. Aust. 189 (5), 261–262.
practice in Australia, health priorities and policies 1998 to 2008. Canberra.
Cooper Robbins, S.C., et al., 2010a. “Is cancer contagious?”: Australian adolescent girls
and their parents: making the most of limited information about HPV and HPV
vaccination voluntary school-based human papillomavirus vaccination: an efficient
and acceptable model for achieving high vaccine coverage in adolescents. Vaccine
28 (19), 3398–3408.
Cooper Robbins, S.C., et al., 2010b. ‘It's a logistical nightmare!’ Recommendations for
optimising human papillomavirus school-based vaccination experience. Sex.
Health 7 (3), 271–278.
Cooper Robbins, S.C., et al., 2010c. “I just signed”: factors influencing decision-making for
school-based HPV vaccination of adolescent girls. Health Psychol. 29 (6), 618–625.
Cooper Robbins, S.C., C. Pang, and J. Leask, in press. Australian newspaper coverage of
HPV vaccination, October 2006-December 2009. Journal of Health Communication.
10–13 years in New South Wales, 2001. N. S. W. Public Health Bull. 14 (1–2), 17–20.
Crawford, N.W., et al., 2011. Syncope and seizures following human papillomavirus
vaccination: a retrospective case series. Med. J. Aust. 194 (1), 16–18.
Creighton, P., et al., 2010. Cervical cancer screening in Australia: modelled evaluation of
the impact of changing the recommended interval from two to three years. BMC
Public Health 10, 734.
Department of Health, 2007. Immunisation Against Infectious Disease – ‘The Green
Book’ – 2006 Updated Edition. Crown Copyright, London.
Donovan, B., et al., 2010. Quadrivalent human papillomavirus vaccination and trends in
genital warts in Australia: analysis of national sentinel surveillance data. Lancet
Infect. Dis. 11 (1), 39–44.
Donovan, B., et al., 2011. A National Program with a National Impact: Quadrivalent HPV
Vaccination and Genital Warts in Australia, 2004–2010. ISSTDR. Quebec city, Canada.
Garland, S.M., et al., in press. Human papillomavirus prevalence among Indigenous and non-
Indigenous Australian women prior to a national HPV vaccination program BMC Med.
Garland, S.M.B., J.M.L., et al., 2008. Human papillomavirus and cervical cancer in Australasia
and Oceania: risk-factors, epidemiology and prevention. Vaccine 26 (Sup. 11), 684.
Garland, S.M., et al., 2009. Natural history of genital warts: analysis of the placebo arm
of two randomized phase iii trials of a quadrivalent HPV (types 6, 11, 16, 18)
vaccine. JID 199 (6), 805–814.
Gertig, D.M., Brotherton, J.M.L., Saville, M., 2011. Measuring human papillomavirus
(HPV) vaccination coverage and the role of the National HPV Vaccination Program
Register, Australia. Sex. Health 8, 171–178.
Gidding, H.F., et al., 2007. Sustained measles elimination in Australia and priorities for
long term maintenance. Vaccine 25 (18), 3574–3580.
Giles, M., Garland, S., 2006. A study of women's knowledge regarding human
papillomavirus infection, cervical cancer and human papillomavirus vaccines.
Aust. N. Z. J. Obstet. Gynaecol. 46 (4), 311–315.
Health, D.o.A., 1997. Guidelines for Adolescent Preventive Services (GAPS). American
Medical Association, Chicago, Illinois.
Heron, L., O'Connor, B., Chant, K., 2003. A cluster randomised controlled trial of three
hepatitis B vaccination programs targeting children in late primary school.
Communicable Diseases Control Conference. Canberra.
Hull, B.P., et al., 2010a. Immunisation coverage annual report, 2008. Commun. Dis.
Intell. 34 (3), 241–258.
Hull, B., et al., 2010b. NSW annual immunisation coverage report, 2009. N. S. W. Public
Health Bull. 21 (9–10), 210–223.
Jacobs, R.J., Meyerhoff, A.S., 2004. Effect of middle school entry requirements on
hepatitis B vaccination coverage. J. Adolesc. Health 34 (5), 420–423.
Juraskova, I., et al., HPV Vaccine Promotion: Does Referring to Both Cervical Cancer and
Genital Warts Affect Intended and Actual Vaccination Behavior? Women's Health
Issues. 21(1): p. 71–79.
Kelly, B.J., et al., 2009. The HPV vaccine and the media: how has the topic been covered
and what are the effects on knowledge about the virus and cervical cancer? Patient
Educ. Couns. 77 (2), 308–313.
Lancucki, L., et al., 2010. A fall-off in cervical screening coverage of younger women in
developed countries. J. Med. Screen. 17, 91–96.
Malcolm, R.L., et al., 2000. The investigation of a ‘cluster’ of hepatitis B in teenagers from an
Marshall, H., et al., 2007. A cross-sectional survey to assess community attitudes to
introduction of human papillomavirus vaccine. Aust. N. Z. J. Public Health 31 (3),
McClelland, A., Liamputtong, P., 2006. Knowledge and acceptance of human
papillomavirus vaccination: perspectives of young Australians living in Melbourne,
Australia. Sex. Health 3 (2), 95–101.
Monteyne, P., Andre, F.E., 2000. Is there a causal link between hepatitis B vaccination
and multiple sclerosis? Vaccine 18 (19), 1994–2001.
National Health and Medical Research Council, 2006. Screening to prevent cervical
cancer: guidelines for the management of asymptomatic women with screen
detected abnormalities[cited; Available from: http://www.nhmrc.gov.au/
NHS National Services Scotland, 2011. SPN immunisations HPV March 2011[cited 25-07-
2011]; Available from: http://www.isdscotlandarchive.scot.nhs.uk/isd/6544.html. 2011.
Nolan, T.M., 2010. The Australian model of immunization advice and vaccine funding.
Vaccine 28, A76–A83.
Pirotta, M.V., et al., 2009a. Patterns of treatment of external genital warts in Australian
sexual health clinics. Sex. Transm. Dis. 36 (6), 375–379.
Pirotta, M.V., Ung, L., C.L., Stein, A., Mast, C., Fairley, C.K., Garland, S.M., 2009b. The
psychosocial burden of HPV-related disease and screening interventions. Sex
Transm. Infect. 85, 508–513.
Pirotta, M., Stein, A., Conway, E.L., Harrison, C., Britt, H., Garland, S.M., 2010. Genital warts
incidence and health care resource utilisation in Australia. Sex. Transm. Infect. 86 (3),
Pitts, M.K., et al., 2007. Knowledge and awareness of human papillomavirus (HPV):
attitudes towards HPV vaccination among a representative sample of women in
Victoria, Australia. Sex. Health 4 (3), 177–180.
a national sample of Australian men and women. Sex. Health 7 (3), 299–303.
Quarterly vaccination coverage statistics for children aged up to five years in the UK
(COVER programme): July to September 2010 Health Protection Report 2010
[cited; Available from: http://www.hpa.org.uk/hpr/archives/2010/hpr5010.pdf.
Queensland Government, Evaluation of theschool based vaccination program 2007–2009.
Stakeholders' Report, Q.H.I. Program, Editor. 2010.
Shand, L., Burney, S., Fletcher, J., 2010. Knowledge of cervical cancer, pap testing and the
human papillomavirus among young Australian women. Health Promot. J. Austr.
21 (3), 202–207.
Sheridan, A. and J. White, Annual HPV vaccine coverage in England 2009/2010, D.o.
Health, Editor. 2011.
Skinner, S.R., I.A., Nolan, T., Lester, R., Glover, S., Bowes, G., 2000. Randomised controlled
trial of an educational strategy to increase school-based adolescent hepatitis B
vaccination. Aust. NZ J. Public Health 24, 298–304.
Skinner, S.R., Cooper Robbins, S.C., 2010. Voluntary school-based human papillomavi-
rus vaccination: an efficient and acceptable model for achieving high vaccine
coverage in adolescents. J. Adolesc. Health 47 (3), 215–218.
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35
Skinner, S.R., Nolan, T., 2001. Adolescent hepatitis B immunisation — should it be the Download full-text
law? Aust. N. Z. J. Public Health 25 (3), 230–233.
Slade, B.A., et al., 2009. Postlicensure safety surveillance for quadrivalent human
papillomavirus recombinant vaccine. JAMA 302 (7), 750–757.
Statistics., A.B.o. 4221.0 - Schools, Australia 2010 [cited.
Stevens, M.P., et al., 2006. Human papillomavirus genotype prevalence in cervical
biopsies from women diagnosed with cervical intraepithelial neoplasia or cervical
cancer in Melbourne, Australia. Int. J. Gynecol. Cancer 16, 1017–1024.
Tota, J., et al., 2010. Promising strategies for cervical cancer screening in the post-
human papillomavirus vaccination era. Sex. Health 7, 376–382.
Ward, K.F., et al., 2010. School-based vaccination in NSW. N. S. W. Public Health Bull. 21
Weisberg, E., et al., HPV vaccination catch up program — utilisation by young Australian
women. Australian Family Physician. 38(1–2): p. 72–6.
S.M. Garland et al. / Preventive Medicine 53 (2011) S29–S35