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HPV vaccination is an important public health tool for preventing most cervical cancers. HPV vaccination coverage has increased significantly in the USAPI since the vaccination program began, and the CNMI now exceeds the WHO 2030 target of ≥90% HPV vaccination series completion coverage. If current coverage trends continue, American Samoa is also on track to meet the WHO 2030 coverage target. In 2023, HPV vaccination rates among adolescent girls aged 13–17 years in American Samoa (95.7%) and the CNMI (97.2%) were higher than those in the three freely associated USAPI jurisdictions (Federated States of Micronesia, Marshall Islands, and Palau) (range = 58.0%–71.4%).
The differences in coverage between USAPI jurisdictions may be at least partially attributable to differences in vaccine access. American Samoa and the Northern Mariana Islands both provide vaccines through school-based vaccination programs and public health clinics. Both jurisdictions receive vaccination program funding and vaccine supply through the Section 317 Immunization Program and the Vaccines for America’s Children (VFC) program. The three Freely Associated Jurisdictions are not eligible for VFC funding and therefore have limited vaccine supply; therefore, these jurisdictions are unable to consistently provide HPV vaccines in clinics or other locations other than schools.
The school-based HPV vaccination program is an evidence-based intervention designed to increase HPV vaccination coverage, particularly in low- and middle-income settings; however, jurisdictional coverage is limited when the vaccine is delivered only in school settings (6For example, secondary school enrollment rates§§§ In the Federated States of Micronesia, the rate is about 66% for girls, 83% in the Marshall Islands, 80% in Palau, and about 97% in American Samoa and the Northern Mariana Islands (7–9). Strategies to reach out-of-school adolescent girls are needed to increase vaccination coverage in these areas. Providing vaccination to girls who are not in school is also an important health equity consideration. Some studies have shown that girls who have dropped out of school are more likely to contract sexually transmitted infections, such as HPV (10).
In addition to the challenge of reaching adolescent girls who are not in school, school-based HPV vaccination programs may have been suspended in some areas during school closures during the COVID-19 pandemic. Palau’s decline in coverage after 2020 may be evidence of the impact of the pandemic, as coverage trended upward among girls who reached the target vaccination age of 11-12 years before 2020 compared with girls who reached age 11-12 years in 2020 and beyond. Additional research is needed to assess the underlying causes of low coverage in freely associated USAPI and to design and implement evidence-based interventions to improve vaccination outcomes appropriate to local contexts. Specific strategies may be needed to increase vaccination coverage among populations that have recently experienced large declines in coverage, including those who are at the recommended vaccination age during the pandemic.
limit
There are at least three limitations to the findings in this report. First, the accuracy of the coverage estimates in this assessment depends on the completeness and accuracy of the jurisdictional IIS data. CDC has worked with jurisdictions to find high completeness and accuracy of vaccination data (i.e., agreement of dose dates and product types recorded between paper and IIS records) for the five USAPI IIS included in this assessment through assessments conducted since 2016. However, IIS data completeness prior to 2016 has not been assessed. Second, the size of the active patient population in the IIS may be inflated compared to census estimates due to difficulties in tracking emigration and deaths, which could lead to an underestimation of vaccination coverage. However, for all jurisdictions included in this assessment, the most recent data from the U.S. Census Bureau were not available for denominator estimates. Therefore, exclusion criteria consistent with the Immunization Registry Operational Modeling Working Group on Management of Active Patient Status Guidelines were applied to retrospectively classify possible active patient status as patients in the IIS for each assessment year. Finally, vaccination coverage in Guam was assessed through a national immunization survey and was therefore not included in this analysis. Differences in methods for estimating vaccination coverage may mean that the results are not directly comparable with other USAPI IIS-based estimates presented in this report.
Implications for public health practice
Only two of the five USAPIs have achieved or are on track to achieve the WHO 2030 target of ≥90% HPV vaccination series completion for girls by age 15 years. Identifying and implementing evidence-based strategies to increase vaccine access and coverage will benefit jurisdictions where coverage is lagging. The USAPI immunization program collaborates with a variety of international governmental, nongovernmental, and academic organizations on immunization and comprehensive cancer control programs. Vaccination coverage data can support its activities by providing performance indicators and data to model health outcomes associated with HPV vaccination, promote health equity, and achieve the WHO 2030 target of 90% HPV vaccination series completion.
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