title: Highest Vaccine Uptake after School-Based Delivery - A County-Level Evaluation of the Implementation Strategies for HPV Catch-Up Vaccination in Sweden.
abstract: BACKGROUND
  The Swedish school-based vaccination programme offers HPV vaccine to girls born ≥1999 in 5-6th grade. In 2012, all counties introduced free-of-charge catch-up vaccination campaigns targeting girls born 1993-1998. Varying vaccine uptake in the catch-up group by December 2012 suggested that some implementation strategies were more successful than others. In order to inform future vaccination campaigns, we assessed the impact of different implementation strategies on the county-level catch-up vaccine uptake.
  
  
  METHODS
  We conducted an ecological study including all Swedish counties (n = 21), asking regional health offices about the information channels they used and where vaccination of the catch-up target group took place in their counties. The uptake of ≥1 dose by 30 September 2014 was estimated using data from the voluntary national vaccination register. We investigated associations between counties' catch-up vaccine uptake, information channels and vaccination settings by calculating incidence rate ratios (IRR) and 95% confidence intervals (CI), using negative binomial regression models.
  
  
  RESULTS
  County level catch-up vaccine uptake varied between 49-84%. All counties offered vaccination through primary health care settings. Apart from this eight (34%) also offered the vaccine in some of their schools, four (19%) in all their schools, and two (10%) in other health care centres. The information channels most frequently used were: information at the national on-line health care consulting web-page (100%), letter/invitations (90%), and advertisement (81%). Counties offering vaccination to girls in all schools and counties offering vaccination in some of their schools, reached higher vaccine uptake compared to counties not offering vaccination in any of their schools (all schools adjusted IRR: 1.3, 95% CI: 1.1-1.5, some schools adjusted IRR: 1.2, 95% CI: 1.1-1.3).
  
  
  CONCLUSIONS
  Counties offering HPV vaccination to catch-up groups in schools reached the highest vaccine uptake. No information channel explained differences in county-level vaccine uptake. Our findings suggest that catch-up vaccination outside the national vaccination program can reach a high uptake at the population level if it is implemented primarily with an organized delivery (e.g. in schools).
authors.affiliation: Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.|European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors.forename: Moa
authors.initials: M
authors.lastname: Rehn
authors.affiliation: Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Uhnoo
authors.affiliation: Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kühlmann-Berenzon
authors.affiliation: Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.|Section for Infectious Diseases, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Wallensten
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden.
authors.forename: Pär
authors.initials: P
authors.lastname: Sparén
authors.affiliation: Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.|Department of Clinical Sciences, Lund University, Malmö, Sweden.|Department of Occupational and Environmental Dermatology Skåne University Hospital, Lund University, Malmö, Sweden.
authors.forename: Eva
authors.initials: E
authors.lastname: Netterlid
mesh_terms: D000293:Adolescent; D000328:Adult; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D053918:Papillomavirus Vaccines / Q000008:administration & dosage*; D012042:Registries; D012574:Schools; D013548:Sweden; D014611:Vaccination
chemical_list: D053918:Papillomavirus Vaccines