1. Overview of HPV vaccination Training GardasilTM
Essential Training Package for HPV Vaccine Introduction
Overview of HPV vaccination Training
GardasilTM

2. Learning objectives
At the end of the module, you will have learned about:
The structure and content of the essential training package
The unique features of HPV vaccination and their implications for practice
Duration
20’

3. Contents of Essential Training Package
Introduction to HPV infection and cervical cancer
HPV vaccine attributes and storage conditions
HPV vaccine eligibility and contraindications
HPV vaccine administration
Recording and monitoring of HPV vaccine doses
Communicating about HPV with key stakeholders
Taking care of adolescent patients
This training will have 7 modules: ( read out on slide)
The total duration of the training will be 1 day ( adapt as necessary)

4. Key considerations for HPV vaccination
Different age group than routine infant vaccination 1
Identifying size of the target population and where they are 2
Implications for communication and social mobilizations 3
New delivery platforms and a combination of strategies 4
In this short overview module we will discuss some key considerations for HPV vaccination
We will focus on the more unique features of HPV vaccination:
Different age group than routine infant vaccination
Challenges in identifying size of the target population and determining where they are
New stakeholders: implications for communication and social mobilization
New delivery platforms will be used and a combination of strategies
HPV vaccination is part of an integrated approach to prevention and control of cervical cancer and adolescent health interventions
HPV vaccination and integrated approaches 5

5. New routine target population: 9 to 13 year old girls
This age group not served by routine immunization programme in the past
Accurate data on the target age group may not be available
Other sectors like education - may have useful data
Where are these girls? In school, at home, do they work?
Girls that do not attend school might be most at risk of getting cervical cancer
Limited health services provided to this age group
New target population
We have good experience with knowing our target population in early childhood, and normally have good data on births cohorts. However, reliable estimates on the size of this target population is less easy to obtain. Often it is the education sector who has useful data on the size of the population
Girls of this age – adolescents in general – do not often come to health services. Therefore we will have to reach out to adolescent girls in order to vaccinate them- That requires us to know where they are: do they attend schools? are they working? are they at home? This will have important implications for the delivery strategy mix that is used
HPV vaccination should reach all girls in the target age group. We cannot content ourselves with reaching all the girls who attend schools, if we know that 10%, 20% or 40% of girls do not go to school. One important reason for this is that the same girls who do not attend school are at higher risk for negative reproductive health outcomes over the life course – they tend to be sexually active earlier, have more children and at an earlier age and have less access to health care including cervical cancer screening. All these factors increase their risk of cervical cancer
Health services in many countries focus their efforts on vaccination and care for newborns and children and on the reproductive and maternal health services of women in reproductive age. When we realize this we see that health facilities normally have limited services to offer to adolescents and particularly to girls in the target age group of HPV vaccination. This offers both an opportunity but also challenges, as we have to learn how to reach and deal with this new age group of clients

6. HPV vaccine: Implications for communication and mobilization
New age group and girls only
Wider set of stakeholders: leaders, parents, girls teachers
Unlike infants, girls are not passive recipients of vaccine: need to communicate with and mobilize girls (Benefits of vaccine, potential side effects, three doses)
Teachers are important mobilizers and communicators for HPV vaccination
Communication and social mobilization on HPV requires additional effort not only because it is new vaccine, but because we need to explain why it is delivered to girls only
There are also more and more diverse stakeholders involved: in addition to community leaders and parents, there is a need to communicate with girls and teachers
One obvious reason that young girls need specific communication is that they are unlike small children: they need to be informed about the vaccine. They need to understand the benefits of vaccination and potential side effects. They also need know that they will get three doses. While parents normally take the decision to vaccinate, girls do a have a say. In addition, we can not assume that all girls are living with their parents or are attending school so some girls may be attending vaccination without parents
Teachers may play a more important role in vaccination than with other vaccines. If vaccines are delivered through schools, health workers may need to contact teachers and provide them with information on HPV vaccination
In module 6 we will come back to communication with key stakeholders and pay specific attention to how to communicate and what the key messages are for parents, teachers and girls.

7. HPV vaccine: Implications for delivery strategies
Combination of delivery strategies for high coverage
fixed site (health centre based)
outreach, e.g. school-based
campaign style
School-based delivery has many considerations
Are all schools participating in HPV vaccination (both private and public)?
When to schedule HPV vaccination in school's timetable?
How to inform and get consent from parents for HPV vaccination?
(Note: Country to adapt to strategy that is chosen, can also be adapted locally within country based on characteristics of the population)
The objective of HPV vaccination is to reach high coverage and particularly reaching those most at risk of cervical cancer.
Different countries use different mix of delivery strategies depending on the infrastructure of the health system, the education system (e.g. existence of a school health program) and other factors
In many countries schools are identified a logical place to vaccinate because many adolescent girls go to school. However, we can not content ourselves with reaching only girls who attend schools, if we know that 20%, 30% or a higher percentage of girls do not go to school. One important reason for this is that the same girls who do not attend school are at higher risk for negative reproductive health outcomes over the life course – they tend to be sexually active earlier, have more children and at an earlier age and overall tend to have less access to health care including cervical cancer screening. All these factors increase their risk of cervical cancer, which we try to prevent through the HPV vaccine.
Therefore we will need a mix of delivery strategies combining school based with community based outreach and fixed site to allow all girls to be identified and vaccinated
School delivery has several implications for vaccination – it requires proper preparation like all outreach activities, in collaboration with the education authorities. Some additional steps may include identifying all the schools in the area, public as well as private. Education authorities may not always have complete list of all schools, in particular of private schools. In some instances, private schools may have different requirements than public school, for example insisting on parental informed consent because of institutional requirements that may not exist in public schools. Vaccination dates need to work with holidays, exam period and other school related issues like teachers' absences due to training

8. an integrated approach (1/3)
HPV vaccination:
an integrated approach (1/3)
Cervical cancer prevention and control across the life course
Linkage to other health services for adolescents
One of the unique features of HPV vaccination is that it is being promoted as part of comprehensive approach to the prevention of cervical cancer. We will learn more about the comprehensive approach to cervical cancer in module 1 when we explore further how the human papilloma virus causes cancer and what the role is of HPV vaccination.
In addition, HPV vaccination is considered an opportunity to strengthen delivery of or seek synergy with other interventions for this age group.
In the following slides we see what implications this may have for HPV vaccination

9. HPV vaccine part of integrated approach (2/3)
Comprehensive cervical cancer prevention and control
Vaccination is primary prevention step in the comprehensive approach to cervical cancer prevention and control
Mothers can be a key audience to ensure vaccination of daughters
Mothers are also an audience for other cervical cancer prevention measures such as screening
One of the implications of the fact that vaccination is primary prevention of cervical cancer prevention and control is that there will be multiple opportunities for dual messaging: for example mothers are a key audience to convince that HPV vaccination is beneficial for their daughters future health.
At the same time, we should use the opportunity to reinforce the message that these mothers and other women should go for cervical cancer screening
We will come back to this in module 6 when we discuss communication with parents

10. Joint delivery of HPV vaccine with other interventions
HPV vaccine part of integrated approach (3/3)
Health services for 9-13 year olds
HPV vaccine delivery is opportunity to strengthen primary health care of adolescents
Joint delivery of HPV vaccine with other interventions
e.g. other vaccines, deworming, menstrual hygiene education, hand washing, malaria education and bed nets, physical activity promotion
The other opportunity that HPV vaccination provides is to strengthen primary health care of adolescents. Reaching out to adolescent girls for HPV vaccination takes a lot of effort and financial resources. It therefore makes sense to capitalize on this investment by identifying opportunities to bring additional health interventions to this age group. Particularly because few health investments are made in this age group of young adolescents.
The ministry of health may therefore decide to seek efficiencies and further improvements in health by jointly delivering HPV vaccine with other interventions. These could be other vaccines, health promotion and education messages, but also other commodities such as bednets or deworming tablets. Given that we will be vaccinating each girls 3 times, there are several opportunities to add interventions. And when we vaccinate girls in schools, the additional interventions could also target boys.
In module 7 we will introduce what is special about adolescence and what the implications of this are for prevention and care of adolescent patients , both in and beyond the context of HPV vaccination.

11. Key messages
9 to 13 year old girls are different target group than routine infant vaccination
Be aware of challenges in identifying the size of the population of girls (9-13 yr) and where they are
HPV vaccine requires special attention to communication and social mobilization
Combination of delivery strategies requires good planning
HPV vaccine offers unique opportunities as it is part of integrated approaches
Read out the key messages on the slide
And finish by asking if there are any questions – and also say that during the modules 1 to 7 we will come back to and go into depth on many of the issues raised in this overview module.