Statistical analyses in Swedish randomised trials on mammography screening and in other randomised trials on cancer screening: a systematic review

Objectives

We compared calculations of relative risks of cancer death in Swedish mammography trials and in other cancer screening trials.

Participants

Men and women from 30 to 74 years of age.

Setting

Randomised trials on cancer screening.

Design

For each trial, we identified the intervention period, when screening was offered to screening groups and not to control groups, and the post-intervention period, when screening (or absence of screening) was the same in screening and control groups. We then examined which cancer deaths had been used for the computation of relative risk of cancer death.

Main outcome measures

Relative risk of cancer death.

Results

In 17 non-breast screening trials, deaths due to cancers diagnosed during the intervention and post-intervention periods were used for relative risk calculations. In the five Swedish trials, relative risk calculations used deaths due to breast cancers found during intervention periods, but deaths due to breast cancer found at first screening of control groups were added to these groups. After reallocation of the added breast cancer deaths to post-intervention periods of control groups, relative risks of 0.86 (0.76; 0.97) were obtained for cancers found during intervention periods and 0.83 (0.71; 0.97) for cancers found during post-intervention periods, indicating constant reduction in the risk of breast cancer death during follow-up, irrespective of screening.

Conclusions

The use of unconventional statistical methods in Swedish trials has led to overestimation of risk reduction in breast cancer death attributable to mammography screening. The constant risk reduction observed in screening groups was probably due to the trial design that optimised awareness and medical management of women allocated to screening groups.     

Cost of starting colorectal cancer screening programs: results from five federally funded demonstration programs

Introduction

In 2005, the Centers for Disease Control and Prevention (CDC) started a 3-year colorectal cancer screening demonstration project and funded five programs to explore the feasibility of a colorectal cancer program for the underserved U.S. population. CDC is evaluating the five programs to estimate implementation cost, identify best practices, and determine the most cost-effective approach. The objectives are to calculate start-up costs and estimate funding requirements for widespread implementation of colorectal cancer screening programs.

Methods

An instrument was developed to collect data on resource use and related costs. Costs were estimated for start-up activities, including program management, database development, creation of partnerships, public education and outreach, quality assurance and professional development, and patient support. Monetary value of in-kind contributions to start-up programs was also estimated.

Results

Start-up time ranged from 9 to 11 months for the five programs; costs ranged from $60,602 to $337,715. CDC funding and in-kind contributions were key resources for the program start-up activities. The budget category with the largest expenditure was labor, which on average accounted for 67% of start-up costs. The largest cost categories by activities were management (28%), database development (17%), administrative (17%), and quality assurance (12%). Other significant expenditures included public education and outreach (9%) and patient support (8%).

Conclusion

To our knowledge, no previous reports detail the costs to begin a colorectal cancer screening program for the underserved population. Start-up costs were significant, an important consideration in planning and budgeting. In-kind contributions were also critical in overall program funding. Start-up costs varied by the infrastructure available and the unique design of programs. These findings can inform development of organized colorectal cancer programs.     

Mammography in asymptomatic women aged 40-49 years

OBJECTIVE

To assess findings of mammography of and interventions resulting from breast cancer screening in women aged 40-49 years with no increased risk (typical risk) of breast cancer.

METHODS

This cross-sectional study evaluated women aged 40-49 years who underwent mammography screening in a mastology reference center in Recife, PE, Northeastern Brazil, between January 2010 and October 2011. Women with breast-related complaints, positive findings in the physical examination, or high risk of breast cancer were excluded.

RESULTS

The 1,000 mammograms performed were classified into the following Breast Imaging-Reporting and Data System (BI-RADS) categories BI-RADS 0, 232; BI-RADS 1, 294; BI-RADS 2, 294; BI-RADS 3, 16; BI-RADS 4A, 2; BI-RADS 5, 1. There was one case of grade II invasive ductal carcinoma and various interventions, including 469 ultrasound scans, 53 referrals to mastologists, 11 cytological examinations, and 8 biopsies.

CONCLUSIONS

Mammography screening in women aged 40-49 years with typical risk of breast cancer led to the performance of other interventions. However, it also resulted in increased costs without demonstrable efficacy in decreasing mortality.     

Economic evaluation of screening for diabetic retinopathy among Chinese type 2 diabetics: a community-based study in Kinmen, Taiwan

Background

This community-based study conducted in Kinmen aimed to discover whether screening for diabetic retinopathy (DR) among Chinese with type 2 diabetes was economically feasible and clinically effective.

Methods

A total of 971 community-dwelling adults previously diagnosed with type 2 diabetes in 1991-1993 underwent DR screening in 1999-2002 by a panel of ophthalmologists, who used on-site indirect ophthalmoscopy and 45-degree color fundus retinal photographs. Economic evaluation included estimates for cost effectiveness and the cost utility of screening for DR.

Results

For each DR case, screening efficacy and utility decreased, while cost increased with the length of the screening interval. The cost per sight year gained in the annual screening, biennial screening, 3-year screening, 4-year screening, 5-year screening, and control groups were New Taiwan dollars (NT$) 20962, NT$ 24990, NT$ 30847, NT$ 37435, NT$ 44449, and NT$ 83411, respectively. The cost per quality-adjusted life year gained by the annual screening, biennial screening, 3-year screening, 4-year screening, 5-year screening, and control groups were NT$ 21924, NT$ 25319, NT$ 30098, NT$ 35106, NT$ 40037, and NT$ 61542, respectively. Threshold values indicate that the screening programs are highly sensitive to screening cost in the plausible range.

Conclusion

Screening for DR is both medically and economically worthwhile. Annual screening for DR among Chinese with type 2 diabetes should be conducted. Prevention programs aimed at improving eye care for patients with type 2 diabetes result in both substantial federal budgetary savings and highly cost-effective health care.Key words: Population, Diabetic Retinopathy, Costs and Cost Analysis, Mass Screening, Diabetes Mellitus Type 2     

Peer Reviewed: Collaboration to Increase Colorectal Cancer Screening Among Low-Income Uninsured Patients

Background

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. CRC screening allows for prevention through the removal of precancerous lesions and early detection of cancer.

Community Context

Ride for Life Alaska (RFL), a nonprofit organization that raises funds to fight cancer, and the Anchorage Neighborhood Health Center (ANHC), which is Alaska''s largest community health center, joined efforts to provide CRC screening and outreach to an ethnically diverse group of low-income underinsured or uninsured patients residing in and around Anchorage, Alaska.

Methods

RFL and ANHC worked with gastroenterologists, medical practices, and pathology services to contribute pro bono and reduced-fee services for CRC screening. Information to patients was distributed through signs in the clinic, flyers, and the ANHC website.

Outcomes

CRC screening was increased in this population. During 2007-2009, there were 2,561 immunochemical fecal occult blood tests given to patients, and 1,558 were completed (61%); 24% were positive. Sixteen gastroenterologists, 4 medical practices, and 2 laboratories provided 111 follow-up colonoscopies and pathology services to patients identified through the CRC screening program who did not have other funding resources available for follow-up care.

Interpretation

This program provides a model for leveraging scarce screening resources by drawing on multiple partners to increase CRC screening. Recommendations for those seeking to initiate similar programs are to have memoranda of agreement in place and a clear scope of work for all participating people and organizations to avoid delays in program implementation; hire a screening care coordinator to manage patient care and collaborate with medical practices; and identify program champions who have the energy and persistence to craft such partnerships.     

A Review of Advocate–Scientist Collaboration in Federally Funded Environmental Breast Cancer Research Centers

Background

The Long Island Breast Cancer Study Project was the first federally funded study of environmental causes of breast cancer. Although advocates were expected to participate in this study, the details of their participation were not adequately clarified in project guidelines, which resulted in confusion over their role in the project. The Breast Cancer and Environment Research Centers (BCERCs) are funded by the National Institute of Environmental Health Sciences and the National Cancer Institute; these centers continue to conduct research into environmental links to breast cancer and to clarify advocate–scientist guidelines for collaboration.

Objectives

Practitioners in community-based participatory research (CBPR) are grappling with how to improve CBPR projects for all groups involved in breast cancer and environmental studies. The ever-growing body of literature on CBPR elaborates on a number of factors that make CBPR particularly challenging, specifically regarding partnerships between advocate and scientific communities. This study draws on CBPR principles to evaluate advocate–scientist collaboration in the BCERCs.

Methods

We conducted surveys at BCERC annual meetings in 2005 and 2007 and 11 in-depth open-ended interviews with key stakeholders such as primary investigators within the centers to assess the perceptions of the advocates and scientists regarding collaboration between advocates and scientists who were engaged in CBPR studies.

Results

We found that although participatory guidelines were a focus of BCERCs, underlying differences between advocates and scientists with regard to paradigms of scientific inquiry, priorities, and desired outcomes need to be addressed for more effective collaboration to take place.

Conclusion

Our findings contribute to the broader CBPR literature by highlighting the role of underlying assumptions that may hinder the collaborative process and suggest the need for continued assessment research into participatory research projects on breast cancer and the environment.     

Peer Reviewed: Case Study of Capacity Building for Smoke-Free Indoor Air in Two Rural Wisconsin Communities

Background

Despite national declines in smoking prevalence, disparities that pose challenges to tobacco control efforts exist among rural manufacturing populations. This community case study sought to better understand the dynamics and nuances that facilitate or impede capacity-building efforts in rural communities.

Context

Two rural manufacturing communities in Wisconsin with similar demographic characteristics were chosen for study. One represented farming communities with close proximity to a metropolitan area, and the other represented more isolated communities.

Methods

The qualitative case study used a collaborative approach to collect data in four areas of research: 1) community context, 2) coalition functioning, 3) partnerships, and 4) strategy implementation. Data were analyzed using standard content analysis and triangulated for clarity and consistency.

Consequences

Although not all the factors found to influence capacity-building efforts were unique to rural environments, the effects were impacted by rural isolation, small population sizes, local attitudes and beliefs, and lack of diversity and resources. Differences in coalition leadership and strategy implementation influenced the effectiveness of the capacity-building efforts in each community, bringing attention to the unique nature of individual contexts.

Interpretation

Implementing capacity-building efforts in rural communities requires skilled and dedicated local leaders who have ready access to training and support (i.e., technical, emotional, and financial). Pairing of rural communities with greater use of distance technologies offers a cost-effective approach to reduce isolation and the constraints of financial and human resources.     

Breast Cancer Screening,Area Deprivation,and Later-Stage Breast Cancer in Appalachia: Does Geography Matter?

Objective

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

Data Source

Central cancer registry data (2006–2008) from three Appalachian states were linked to Medicare claims and census data.

Study Design

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

Principal Findings

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged >75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

Conclusions

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.     

Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

PURPOSE

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation.

METHODS

We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers.

CONCLUSIONS

Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.     

Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania

Objective

To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania.

Methods

Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi’s model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care.

Findings

Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts.

Conclusion

The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.     

Willingness to participate in trials and to be vaccinated with new tuberculosis vaccines in HIV-infected adults

Background:

New tuberculosis (TB) vaccines are required to meet global targets for TB control.

Objectives:

To determine willingness to participate (WTP) in new TB vaccine trials, willingness to be vaccinated with a newly licensed TB vaccine and associated factors among human immunodeficiency virus (HIV) infected persons.

Setting:

Two primary care clinics in South Africa.

Design:

Cross-sectional study design. Participants were asked about WTP and willingness to be vaccinated. Demographic, clinical, knowledge of TB and perception of risk information were collected. Log binomial regression was used to determine associated factors.

Results:

A total of 827 participants were included in the analysis: 80.4% female, 72.2% on antiretroviral therapy, median age 35 years (interquartile range [IQR] 29–42 years), CD4 count 523 cells/µl (IQR 427–659 cells/µl). WTP and willingness to be vaccinated were high, at 84.5% and 92.6%, respectively. WTP was associated with knowledge about TB (prevalence ratio [PR] 1.10, 95% confidence interval [CI] 1.03–1.17) and perception of risk (PR 1.07, 95%CI 1.01–1.13). Willingness to be vaccinated was associated with employment (PR 1.04, 95%CI 1.01–1.08) and perception of risk (PR 1.05, 95%CI 1.01–1.09).

Conclusions:

There was high WTP in TB vaccine trials and willingness to be vaccinated among HIV-infected patients with good TB knowledge and high perceived risk of contracting TB.     

Integration of comprehensive women’s health programmes into health systems: cervical cancer prevention,care and control in Rwanda

Problem

Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda.

Approach

By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment.

Local setting

Rwanda – a small, landlocked nation in East Africa with a population of 10.4 million – is well positioned to tackle a number of “high-burden” noncommunicable diseases. The country’s integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade.

Relevant changes

In 2011–2012, Rwanda vaccinated 227 246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options.

Lessons learnt

Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women’s health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.     

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial

PURPOSE

The purpose of this study was to evaluate a primary care practice–based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates.

METHODS

The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up.

RESULTS

Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients’ colorectal cancer screening rates. Qualitative analyses provide insights into practices’ QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates.

CONCLUSIONS

Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.     

Peer Reviewed: Differences in Knowledge of Breast Cancer Screening Among African American,Arab American,and Latina Women

Introduction

We examined differences in knowledge and socioeconomic factors associated with 3 types of breast cancer screening (breast self-examination, clinical breast examination, and mammogram) among African American, Arab, and Latina women.

Methods

Community health workers used a community-based intervention to recruit 341 women (112 Arab, 113 Latina, and 116 African American) in southeastern Michigan to participate in a breast cancer prevention intervention from August through October 2006. Before and after the intervention, women responded to a previously validated 5-item multiple-choice test on breast cancer screening (possible score range: 0 to 5) in their language of preference (English, Spanish, or Arabic). We used generalized estimating equations to analyze data and to account for family-level and individual correlations.

Results

Although African American women knew more about breast cancer screening at the baseline (pretest median scores were 4 for African American, 3 for Arab and 3 for Latina women), all groups significantly increased their knowledge after participating in the breast cancer prevention intervention (posttest median scores were 5 for African American and 4 for Arab and Latina women). Generalized estimating equations models show that Arab and Latina women made the most significant gains in posttest scores (P < .001).

Conclusion

Racial/ethnic differences in knowledge of breast cancer screening highlight the need for tailored information on breast cancer screening for African American, Arab, and Latina women to promote adherence to breast cancer screening guidelines.     

Application of Geographic Information Systems and Asset Mapping to Facilitate Identification of Colorectal Cancer Screening Resources

Objective

We sought to identify and map the geographic distribution of available colorectal cancer screening resources; following identification of this priority within a needs assessment of a local community-academic collaborative to reduce cancer health disparities in medically underserved communities.

Methods:

We used geographic information systems (GIS) and asset mapping tools to visually depict resources in the context of geography and a population of interest. We illustrate two examples, offer step-by-step directions for mapping, and discuss the challenges, lessons learned, and future directions for research and practice.

Results:

Our positive asset driven, community-based approach illustrated the distribution of existing colonoscopy screening facilities and locations of populations and organizations who might use these resources. A need for additional affordable and accessible colonoscopy resources was identified.

Conclusion:

These transdisciplinary community mapping efforts highlight the benefit of innovative community-academic partnerships for addressing cancer health disparities by bolstering infrastructure and community capacity-building for increased access to colonoscopies.     

Innovative public–private partnership: a diagonal approach to combating women’s cancers in Africa

Problem

In low- and middle-income countries, breast and cervical cancer have a poor prognosis, partly owing to barriers to treatment. To redress this situation, health systems must be strengthened.

Approach

Pink Ribbon Red Ribbon (PRRR) is an innovative partnership designed to leverage public and private investments in global health and to build on the successful United States President’s Emergency Plan for AIDS Relief (PEPFAR) platform to combat cancers of the breast and cervix in sub-Saharan Africa and Latin America. By supporting a comprehensive set of country-owned and country-driven interventions, PRRR seeks to reduce deaths from cervical cancer among women screened and treated through the programme and to reduce deaths from breast cancer by promoting early detection.

Local setting

In its initial phase, PRRR is supporting the governments of Botswana, Zambia and other countries in expanding cervical cancer prevention, screening and treatment coverage – especially to high-risk women with human immunodeficiency virus infection – and in strengthening breast cancer education and control services.

Relevant changes

PRRR has introduced a diagonal strategy based on the life course and continuum of care approaches to cancer control. Its work has resulted in the delivery of the human papillomavirus vaccine to young girls in several settings and in the strengthening of prevention, screening and treatment delivery systems from the community to the tertiary level.

Lessons learnt

This paper outlines the approach PRRR has taken as a country-aligned public–private partnership and the preliminary lessons learnt, including the need for flexible implementation, effective country coordination mechanism and regular communication with all stakeholders.     

Peer Reviewed: Design and National Dissemination of the StrongWomen Community Strength Training Program

Background

Physical activity is essential for maintaining health and function with age, especially among women. Strength training exercises combat weakness and frailty and mitigate the development of chronic disease. Community-based programs offer accessible opportunities for strength training.

Program Design

The StrongWomen Program is an evidence-informed, community-based strength training program developed and disseminated to enable women aged 40 or older to maintain their strength, function, and independence. The StrongWomen Workshop and StrongWomen Tool Kit are the training and implementation tools for the StrongWomen Program. Program leaders are trained at the StrongWomen Workshop. They receive the StrongWomen Tool Kit and subsequent support to implement the program in their communities.

Dissemination

Program dissemination began in May 2003 with a three-part approach: recruiting leaders and forming key partnerships, soliciting participant interest and supporting implementation, and promoting growth and sustainability.

Assessment

We conducted site visits during the first year to assess curriculum adherence. We conducted a telephone survey to collect data on program leaders, participants, locations, and logistics. We used a database to track workshop locations and program leaders. As of July 2006, 881 leaders in 43 states were trained; leaders from 35 states had implemented programs.

Conclusion

Evidence-informed strength training programs can be successful when dissemination occurs at the community level using trained leaders. This research demonstrates that hands-on training, a written manual, partnerships with key organizations, and leader support contributed to the successful dissemination of the StrongWomen Program. Results presented provide a model that may aid the dissemination of other community-based exercise programs.     

Identification of Abnormal Screening Mammogram Interpretation Using Medicare Claims Data

Objective

To develop and validate Medicare claims-based approaches for identifying abnormal screening mammography interpretation.

Data Sources

Mammography data and linked Medicare claims for 387,709 mammograms performed from 1999 to 2005 within the Breast Cancer Surveillance Consortium (BCSC).

Study Design

Split-sample validation of algorithms based on claims for breast imaging or biopsy following screening mammography.

Data Extraction Methods

Medicare claims and BCSC mammography data were pooled at a central Statistical Coordinating Center.

Principal Findings

Presence of claims for subsequent imaging or biopsy had sensitivity of 74.9 percent (95 percent confidence interval [CI], 74.1–75.6) and specificity of 99.4 percent (95 percent CI, 99.4–99.5). A classification and regression tree improved sensitivity to 82.5 percent (95 percent CI, 81.9–83.2) but decreased specificity (96.6 percent, 95 percent CI, 96.6–96.8).

Conclusions

Medicare claims may be a feasible data source for research or quality improvement efforts addressing high rates of abnormal screening mammography.     

Achieving high coverage in Rwanda's national human papillomavirus vaccination programme

Problem

Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275 000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years.

Approach

In 2011, Rwanda’s Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a “public–private community partnership” to ensure effective and equitable delivery.

Local setting

Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12–23 months receive all basic immunizations recommended by the World Health Organization.

Relevant changes

In 2011, Rwanda’s HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose.

Lessons learnt

Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda’s strong vaccination system and human resources framework. Following the GAVI Alliance’s decision to begin financing HPV vaccination, Rwanda’s example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context.