title: Introduction of a National HPV vaccination program into Bhutan.
abstract: BACKGROUND
  Cervical cancer is the most common cancer in Bhutanese women. To help prevent the disease, the Ministry of Health (MoH) developed a national human papillomavirus (HPV) vaccine program.
  
  
  METHODS
  MoH considerations included disease incidence, the limited reach of cervical screening, poor outcomes associated with late diagnosis of the disease, and Bhutan's ability to conduct the program. For national introduction, it was decided to implement routine immunization for 12 year-old girls with the quadrivalent HPV6/11/16/18 (QHPV) vaccine and a one-time catch-up campaign for 13-18 year-old girls in the first year of the program (2010). Health workers would administer the vaccine in schools, with out-of-school girls to receive the vaccine at health facilities. From 2011, HPV vaccination would enter into the routine immunization schedule using health-center delivery.
  
  
  RESULTS
  During the initial campaign in 2010, over 130,000 doses of QHPV were administered and QHPV 3-dose vaccination coverage was estimated to be around 99% among 12 year-olds and 89% among 13-18 year-olds. QHPV vaccine was well tolerated and no severe adverse events were reported. In the three following years, QHPV vaccine was administered routinely to 12 year-olds primarily through health centers instead of schools, during which time the population-level 3-dose coverage decreased to 67-69%, an estimate which was confirmed by individual-level survey data in 2012 (73%). In 2014, when HPV delivery was switched back to schools, 3-dose coverage rose again above 90%.
  
  
  CONCLUSIONS
  The rapid implementation and high coverage of the national HPV vaccine program in Bhutan were largely attributable to the strength of political commitment, primary healthcare and support from the education system. School-based delivery appeared clearly superior to health centers in achieving high-coverage among 12 year-olds.
  
  
  CONCLUSIONS
  Bhutan's lessons for other low/middle-income countries include the superiority of school-based vaccination and the feasibility of a broad catch-up campaign in the first year.
authors.affiliation: Communicable Disease Division, Department of Public Health, Ministry of Health, Thimphu, Bhutan. Electronic address: tandindorji@health.gov.bt.
authors.forename: Tandin
authors.initials: T
authors.lastname: Dorji
authors.affiliation: Department of Obstetrics & Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan. Electronic address: ugentshomo2000@yahoo.com.
authors.forename: Ugyen
authors.initials: U
authors.lastname: Tshomo
authors.affiliation: Communicable Disease Division, Department of Public Health, Ministry of Health, Thimphu, Bhutan. Electronic address: sangayp2014@gmail.com.
authors.forename: Sangay
authors.initials: S
authors.lastname: Phuntsho
authors.affiliation: Communicable Disease Division, Department of Public Health, Ministry of Health, Thimphu, Bhutan. Electronic address: ttamang@health.gov.bt.
authors.forename: Tshewang Dorji
authors.initials: TD
authors.lastname: Tamang
authors.affiliation: Department of Laboratory Services, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan. Electronic address: doc_tshokey@yahoo.com.
authors.forename: Tshokey
authors.initials: T
authors.lastname: Tshokey
authors.affiliation: International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon Cedex 08, France. Electronic address: baussanoi@iarc.fr.
authors.forename: Iacopo
authors.initials: I
authors.lastname: Baussano
authors.affiliation: International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon Cedex 08, France. Electronic address: franceschis@iarc.fr.
authors.forename: Silvia
authors.initials: S
authors.lastname: Franceschi
authors.affiliation: International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon Cedex 08, France. Electronic address: cliffordg@iarc.fr.
authors.forename: Gary
authors.initials: G
authors.lastname: Clifford
mesh_terms: D000293:Adolescent; D001631:Bhutan / Q000453:epidemiology; D002648:Child; D005260:Female; D006291:Health Policy; D000068857:Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18 / Q000008:administration & dosage* / Q000276:immunology*; D006801:Humans; D017589:Immunization Programs; D030361:Papillomavirus Infections / Q000150:complications / Q000453:epidemiology / Q000517:prevention & control*; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology / Q000517:prevention & control*; D014611:Vaccination / Q000379:methods*
chemical_list: D000068857:Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18
keywords: Bhutan; Cervical cancer; Human papillomavirus; Vaccination