Achieving High Uptake of Human Papillomavirus Vaccination in Malaysia through School-based Vaccination Programme

"Involvement of various stakeholders and gatekeepers facilitated the public acceptance of a new and potentially controversial vaccine."

This paper examines the multisectoral and integrated collaborative structure and process created as part of Malaysia's school-based human papillomavirus (HPV) immunisation programme. It looks at how the various strategies used in the implementation period (2010-2016), including communication strategies, which were unique to the Malaysian context were successful in achieving optimal coverage of the intended population.

As explained here, in 2006, the Ministry of Health, Malaysia (MOH) began 4 years of planning to implement the HPV vaccination programme. Prior to 2010, cytology-based screening was the main preventive measure for cervical cancer in Malaysia. Lack of knowledge about the disease, inadequate health literacy, low perception of cancer risk, certain behaviours and attitudes towards the preventive programme, and lack of systematic, population-based, active recruitment approaches to women were the factors that contributed to the low percentage of women seeking and receiving the service. Therefore, an HPV vaccination programme was developed for 13-year-old school girls in Malaysia as part of its cancer prevention strategy.

High rates of school enrolment for 13-year olds (96.0%) and retention of female students in secondary schools have made it possible for the HPV vaccination to be integrated into the School Health Service Program and to ensure equal access to the HPV vaccine between urban and rural areas. At the onset of the launch in 2010, 450 school health teams were readily available to deliver the services throughout the country for both public and private schools.

Introduction of HPV vaccine particularly involves supporting the acceptability of the vaccines to adolescent girls, who may have little or no knowledge about cervical cancer, and parents, who may be suspicious of the vaccines. This is particularly the case if they are exposed to negative media coverage. To proactively address communication requirements, all public enquiries on the HPV immunisation were responded to by a public health physician and paramedics who were put on-call on a rotational basis to answer telephone hotlines as well as any queries from implementers at schools or health clinics. Furthermore, parents were provided with HPV vaccine information through print and electronic media to enable them to make independent, informed choices about whether to vaccinate their daughters.

Electronic, printed, and social media were the main communication channels employed in creating public awareness towards accepting HPV vaccination. The messages were tailored to the local cultural context, religion, and information needs of parents, girls, and the general public. They were designed to alleviate fear and misconception about the vaccine being new, while reinforcing vaccine safety. Major telecommunication stations, newspapers, and magazines were engaged to air the HPV messages 5 months prior to starting the programme. Multiple campaigns regarding the vaccines and its availability were featured at prime time on main communication channels and on billboards. Traditional and social media outlets were very active during the first 2 years of the launch. Information such as the programme website link was provided in every pamphlet and poster and also in electronic media. A specific tagline and a logo were created by Health Education Division, Department of Public Health, MOH. It was designed in a way so that female students could associate themselves with HPV vaccination.

Negative feedback and reporting on HPV vaccination abroad and locally were closely monitored and addressed accordingly to alleviate fear among the public and the intended population. Furthermore, active adverse event following immunisation (AEFI) monitoring was introduced to create students' and parental awareness on the vaccine and vaccination safety. Any adverse event would be reported for every dose of immunisation. Active reporting was encouraged by providing an AEFI form to all recipients.

The paper outlines the results of the process, sharing data such as, for example, the fact that 93.35% students with parental consent completed their 3 doses of vaccination in 2010. This figure improved to 98.3% in 2011 and increased to 99.3%, 99.4%, and 99.6% in 2012, 2013, and 2014, respectively.

According to the researchers, some of the elements that made the programme successful include political will and commitment and smart partnerships with relevant stakeholders. For instance, the existing relationship with the Ministry of Education (MOE) was an enabling factor in facilitation of voluntary parental consent through schools. Collaboration with MOE was strengthened at national, state, district, and operational levels. Interactive discussion between school administrative and school health teams was carried out regularly, as were frequent discussions with relevant government agencies, professional bodies, and non-governmental agencies to gain their continuous support and commitment. In addition, MOH worked with Malaysian religious authorities to issue an Islamic ruling (fatwa) on HPV vaccination. The ruling stipulates "Immunising women with HPV vaccine that has been determined to have no element of doubt in its content and will not harm the recipient, is permissible for the prevention of cervical cancer."

In conclusion: "A multisectoral and integrated collaborative structure and process ensured that the Malaysia school-based HPV immunisation programme was successful and sustained through the programme design, planning, implementation and monitoring and evaluation."