WHO/Europe is working with immunization programmes across the European Region to help them raise awareness about HPV vaccination, address obstacles to high uptake and prepare for HPV vaccine introduction where it is not yet part of the routine immunization programme. As part of this work WHO/Europe has led or collaborated in the production of information materials, including the following resources: Video: HPV and cervical cancer – a personal story Video: How the HPV vaccine works Video: Monitoring the side effects of the HPV vaccine Q&A about the HPV virus and vaccine Talking with patients and parents about HPV vaccination for girls: Information for health care professionals A field guide to qualitative research for new vaccine introduction
To access these and more WHO resources related to HPV go to: http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/vaccine-preventable-diseases/human-papillomavirus-hpv2

Dear Friends, I share the following story recently published in the New York Times on the leveraging of policy to bring about quick change in measles coverage in California, USA following the measles outbreak of 2014. The story can be obtained from here with all accompanying graphics: https://nyti.ms/2ELhglu The text of the story is pasted below for those who are in settings where the New York Times article may not open correctly on your computer. Enjoy. + + + + + + + + +  After a Debacle, How California Became a Role Model on Measles
Changing minds on vaccination is very difficult, but it isn’t so important when a law can change behavior. By Emily Oster and Geoffrey Kocks Jan. 16, 2018 In December 2014 something unusual happened at Disneyland. People came to visit Mickey Mouse, and some of them left with measles. At least 159 people contracted the disease during an outbreak lasting several months. This is more than the typical number in a whole year in the United States. The leading theory is that measles was introduced in Disneyland by a foreign tourist. That could happen anywhere. Medical experts generally agree that the fact that it took off was probably a result of California’s low vaccination rates, which in turn was a result of an inability to persuade a significant share of Californians that vaccines were important. The episode made national news, but in the next few years, another development was striking but attracted less national attention: Because of a policy change, California was able to turn it around. Data from a county-by county analysis shows that in many schools with the lowest vaccination rates, there was an increase of 20 to 30 percentage points in the share of kindergartners vaccinated between 2014 and 2016. One law changed the behavior of impassioned resisters more effectively than a thousand public service announcements might have. Limiting outbreaks of vaccine-preventable diseases relies on “herd immunity.” Essentially, if enough people are vaccinated, a disease cannot get a foothold. For measles, this number is around 90 percent to 95 percent. In other words, if 95 percent of people in an area are vaccinated for measles, an outbreak is unlikely even if the disease is introduced. Our best data on vaccination rates, in California and elsewhere, relies on records collected from schools at kindergarten entry. California requires these records from all schools, public and private, so they provide a comprehensive measure. In 2014, for California over all, about 93 percent of entering kindergartners were vaccinated for measles. This wasn’t bad. It could have been better — a place like North Carolina is at about 98 percent — but this was a high enough rate to be in the range of herd immunity. The trouble is that herd immunity is about the vaccination rate among the people you interact with, and you’re not interacting with the entire state of California. Local vaccination rates matter. If the overall state vaccination rate of 93 percent was because each area had a vaccination rate of 93 percent, that would be one thing. But if it’s because a bunch of areas had very high rates, and a bunch had lower ones, that’s quite another. And this second case was California in 2014. The accompanying chart gives a sense of the distribution of vaccination rates across counties in California in 2014. In 2014, there were a lot of areas of California with very low vaccination rates. If we take the herd immunity rate to be 95 percent, 70 percent of children were in counties below that rate. Even taking the bottom of the herd immunity range — 90 percent — found 36 percent of children in counties below that rate. A focus on individual schools was even more striking. At the Berkeley Rose School, in Alameda County, only 13 percent of kindergarten students were up to date on vaccinations in 2014. George De La Torre Jr. Elementary, in Los Angeles, was at 14 percent. The Community Outreach Academy, a large public school in Sacramento, was at 46 percent. These were on the lower end — but they were not the lowest rates. There were two ways a student could be unvaccinated in 2014 in the California public schools. Some students were admitted “conditionally” — that is, not fully vaccinated but planning to be soon. Other students had a formal “personal belief exemption.” That is, for religious or other reasons — often misplaced fears of vaccine injury — the parents could choose not to vaccinate their children at all. These varied greatly across schools. In the Berkeley Rose School, a private Waldorf school, all of the unvaccinated students (87 percent of the kindergartners) had personal belief exemptions. In elementary schools in poorer parts of Los Angeles, the lack of up-to-date vaccination was due mostly to conditional enrollment. In practice, in this period there was little follow-up on the vaccination of conditionally enrolled students, so conditional non-vaccination could easily turn into long-term non-vaccination. In the end, the result was the same: many schools with many unvaccinated children, and they were at risk. Measles is extremely contagious. If you introduce it into a school where only 13 percent of students are vaccinated, a lot of people will become ill. In response to the Disneyland outbreak, California suddenly went from a state with quite lax school vaccination standards to one with extremely strict requirements. The state passed Senate Bill 277, which went into effect in 2016 and eliminated all personal belief exemptions and tightened the approach to conditionally enrolled students. No longer could a parent say, “I’ll do it later”; there had to be a plan for vaccine completion over a period of about six months. The only remaining exemptions were for medical reasons. And since all schools, public and private, have to report the vaccination status of enrolled children, including documentation, the state has a way to monitor this. Without seeing your vaccination records, a school simply is not allowed to enroll you. And children have to be enrolled in school. Public health researchers have studied the relationship between state vaccination rules and vaccination rates, and have generally found that stricter vaccination laws generate higher vaccination rates on average. But these studies tend to focus on state levels over all, rather than on the distribution. In a place like California, with so many low-vaccination schools, we had a chance to ask: What would actually happen? What happened was that people got vaccinated. In 2016, 97 percent of children lived in counties with a kindergarten vaccination rate above 95 percent, and a full 99.5 percent in places over 90 percent. Looking at the school level, we can see which schools contributed to this change. We took schools in 2014 and divided them into 10 groups based on their vaccination rates. For each group of schools, we calculated their vaccination rates in 2014 and 2016. This provided a way to summarize which group of schools accounted for the changes over time. In the accompanying chart, we see the results. Schools in the bottom group had about 60 percent of their students up to date on vaccines in 2014. This is pretty abysmal, and this is an average, so many places were even lower. By 2016, this group had close to a 90 percent vaccination rate. It was an astonishing 25-percentage-point increase in vaccinations over a period of just two years. When we look at what drives this, one big factor is a huge decline in the conditional enrollment numbers. In George De La Torre Jr. Elementary, where 86 percent of children were conditionally enrolled with no measles vaccine in 2014, the vaccination rate in 2016 was 99 percent. But perhaps more striking are the changes for places where personal belief exemptions were high, places where there was concern that people were really committed to no vaccinations. In the Community Outreach Academy, the vaccination rate increased to 83 percent from 46 percent over this period. This was almost entirely a result of reductions in personal belief exemptions. And what about the Berkeley Rose School, with its 87 percent personal belief exemption rate? By 2016, 57 percent of entering students were vaccinated — a huge change, and that was only in the first year of the law. When SB 277 was passed, people worried about the possible effects: Would children be pulled out of school? This concern was misplaced. Over all, there has been no change in enrollment, even in schools with the lowest vaccination rates in 2014. People worried that parents would substitute (fake) medical exemptions for belief exemptions. This did happen, a little, but not nearly enough to offset the increases. In the end, the effect of the law was simple: More children were vaccinated, and the risk of disease outbreaks has gone down. Under-vaccination is a significant policy problem. As earlier generations knew, people die of measles, and of whooping cough, and of other diseases that vaccines can prevent. Figuring out how to increase vaccination is a challenge. We often rely on education, but it is hard to change people’s minds on this topic, as doctors and policymakers — as well as any parents who have engaged on an internet message board — know all too well. From a policy standpoint, these findings offer a ray of hope for vaccine proponents. Maybe changing minds isn’t so important. People may not have altered their attitudes about vaccination, but the fact is that these laws actually changed behavior. In Oregon, parents can opt out of getting their children immunized by completing a 15-minute online “education” module. Many of them do: The share of people in Oregon counties with kindergarten vaccination rates over 95 percent was close to 100 percent in 2000; in 2015, it was about 30 percent. Perhaps lawmakers there and in other states should consider a more stringent exemption policy before, not after, they have their own measles outbreak.  

Immunization, urbanization and slums – a systematic review of factors and interventions Tim Crocker-Buque, Godwin Mindra, Richard Duncan and Sandra Mounier-Jack BMC Public Health 2017, 17:556 | Published on: 8 June 2017 Abstract Background In 2014, over half (54%) of the world’s population lived in urban areas and this proportion will increase to 66% by 2050. This urbanizing trend has been accompanied by an increasing number of people living in urban poor communities and slums. Lower immunization coverage is found in poorer urban dwellers in many contexts. This study aims to identify factors associated with immunization coverage in poor urban areas and slums, and to identify interventions to improve coverage. Methods We conducted a systematic review, searching Medline, Embase, Global Health, CINAHL, Web of Science and The Cochrane Database with broad search terms for studies published between 2000 and 2016. Results Of 4872 unique articles, 327 abstracts were screened, leading to 63 included studies: 44 considering factors and 20 evaluating interventions (one in both categories) in 16 low or middle-income countries. A wide range of socio-economic characteristics were associated with coverage in different contexts. Recent rural-urban migration had a universally negative effect. Parents commonly reported lack of awareness of immunization importance and difficulty accessing services as reasons for under-immunization of their children. Physical distance to clinics and aspects of service quality also impacted uptake. We found evidence of effectiveness for interventions involving multiple components, especially if they have been designed with community involvement. Outreach programmes were effective where physical distance was identified as a barrier. Some evidence was found for the effective use of SMS (text) messaging services, community-based education programmes and financial incentives, which warrant further evaluation. No interventions were identified that provided services to migrants from rural areas. Conclusion Different factors affect immunization coverage in different urban poor and slum contexts. Immunization services should be designed in collaboration with slum-dwelling communities, considering the local context. Interventions should be designed and tested to increase immunization in migrants from rural areas.

People who delay or refuse vaccines for themselves or their children are presenting a growing challenge for countries seeking to close the immunization gap. Globally, 1 in 5 children still do not receive routine life-saving immunizations, and an estimated 1.5 million children still die each year of diseases that could be prevented by vaccines that already exist, according to WHO. In a special issue of the journal Vaccine, guest-edited by WHO and published on 18.08.2015, experts review the role of vaccine hesitancy in limiting vaccine coverage and explore strategies to address it. Vaccine hesitancy refers to delay in acceptance or refusal of safe vaccines despite availability of vaccination services. The issue is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as misinformation, complacency, convenience and confidence. The authors of the editorial of the journal note, “As the recent Ebola crisis tragically brought to light, engaging with communities and persuading individuals to change their habits and behaviours is a lynchpin of public health success. Addressing vaccine hesitancy is no different.” The recommendations proposed by WHO aim to increase the understanding of vaccine hesitancy, its determinants and challenges. They also suggest ways organizations can increase acceptance of vaccines, share effective practices, and develop new tools to assess and address hesitancy. Factors contributing to vaccine hesitancy Concerns about vaccine safety can be linked to vaccine hesitancy, but safety concerns are only one of many factors that may drive hesitancy. Vaccine hesitancy can be caused by other factors such as: negative beliefs based on myths, e.g. that vaccination of women leads to infertility; misinformation; mistrust in the health care professional or health care system; the role of influential leaders; costs; geographic barriers and concerns about vaccine safety. There is no “magic bullet,” or single intervention strategy that works for all instances of vaccine hesitancy and the magnitude and setting of the problem varies and must be diagnosed for each instance to develop tailored strategies to improve vaccine acceptance. Vaccine hesitancy is not only an issue in high income countries, but is a complex, rapidly changing global problem that varies widely. Interviews with immunization managers from WHO regions revealed that while in some cases particular rural ethnic minorities and remote communities were affected; in other areas wealthy urban residents expressed concerns regarding vaccine safety. In some areas concerns are related to subgroups of religious or philosophical objectors. Determinants of vaccine hesitancy can act both as barriers and promoters: For example, a higher level of education does not necessarily predict vaccine acceptance, the experts note. In fact, a number of studies identify higher education as a potential barrier to vaccine acceptance in some settings, while other studies identify education as a promoter of vaccine acceptance in different areas. Even fear of needles can be a factor for vaccine refusal and WHO will issue, in September 2015, a position paper on pain mitigation.