Back to school

1 February 2010

As schools go back this month so will public health nurses as they start the second year of a cervical cancer vaccine “catch-up” programme in schools. FIONA CASSIE finds out more

A vaccine to prevent cancer is often seen as a pipe dream. So when a vaccine did emerge that could radically reduce the risk of cervical cancer, the New Zealand government followed others around the world in adding it to their immunisation schedules for 2009.

So far just over half the girls and young women offered the vaccine at schools through a public health nurse-delivered campaign have taken it up.

Laurie Mahoney, chair of the Public Health Nurse Section of NZNO, is not surprised by the campaign’s relatively modest beginnings in schools. She points out that not only was it a new vaccine, it also makes the link between sexual behaviour and the HPV (Human Papillomavirus) infections that are the cause of nearly all cervical cancers.

Likewise, Nikki Turner, director of the University of Auckland-based Immunisation Advisory Centre, says she was not at all surprised at last year’s uptake for a vaccine that is still so new.

She says with surveys showing a large knowledge gap about HPV infection, a lot more education is still needed for people to understand the need for an HPV vaccine.

“But we’re not in an epidemic control situation here, so my feeling is go slow and steady and give people time to get their heads around it.”

John Holmes, the Ministry of Health’s chief population health advisor, says the ministry is pleased with the “slow and steadily climbing” uptake while recognising that some parents may be taking a “wait and see” approach to what is a new immunisation for New Zealand.

When Nursing Review talked to Laurie Mahoney and some of her fellow public health nurse section committee members, based from Auckland to Dunedin, it was clear that nurses have encountered parental wariness about vaccinating their daughters. Winning over parents is important as parental consent is needed up to the age of 16. Some regions also reported schools declining to take part – including a number of Christian schools and in one case a city’s most liberal school.

PHN section committee members say nurses did have some parents asking why they should vaccinate their 12-year-old when she was not sexually active and would not be for some time. That reluctance might be behind one region reporting an uptake of the vaccine by less than a fifth of Year 8 students last year. Also, in some middle class areas there is already quite a pronounced anti-immunisation movement. The section nurses say the questioning of the vaccine may be reflected in the lower level of New Zealand European girls’ uptake of the vaccine compared with the higher uptake by Pacific and Māori girls (71 per cent and 62 per cent respectively).

The nurses agree that wariness about vaccination is not helped by lack of data on the longevity of the vaccine. They also point out that with such a new vaccine, researchers naturally can not make any claims about life-long immunity.

But the Ministry of Health chief advisor for child and youth, Pat Tohy, has said ongoing clinical studies are showing that five years after immunisation protection remains high and with no sign of weakening, which suggests protection will last much longer – possibly for life.

Adverse reactions are not seen as an issue by the NZNO section nurses, with Laurie Mahoney saying the vaccine actually appears to have fewer side effects – like fainting or headaches – than other vaccines delivered at the same age.

By the end of 2009, 236 mostly minor adverse reactions like swelling at the injection site had been reported to the Centre for Adverse Reactions Monitoring at Otago University – about one response for every thousand doses.

The New Zealand Herald reported in January that a grieving mother believed her daughter’s unexplained death in September – six months after receiving her third Gardasil dose – was linked to the vaccine. Medsafe, the Ministry of Health’s medicines safety arm, has said it is awaiting the coroner’s report, but that 44 million doses had been distributed worldwide without raising any safety concerns.

The nurses did report some disappointment with fall-off after the first dose of the vaccine and reported a variety of strategies to combat this. One region had a nursing team that dedicated the school holidays to tracking down girls and was pleased that 90 per cent had so far received all three doses. Other regions had dedicated Māori and Pacific health workers or whānau support workers following up missed doses or non-returned consent forms. Yet others had nurses setting up displays in shopping malls and temporary vaccination booths during the school holidays.

With a long-term population health focus, the public health nurses are realistic that it may take time to convince the general population of the vaccine’s worth. But with already anecdotal evidence emerging in New Zealand about a reduction in genital warts, they are optimistic that immunisation could make a difference in more ways than reducing cervical cancer rates. Holmes said University of Melbourne research was already backing this, with the number of women aged under 28 diagnosed with genital warts falling 25 per cent each quarter throughout 2008, following the start of the Australian HPV immunisation programme in July 2007.

The public health sector is now gearing up for a second “catch-up” campaign in schools and the chance to use education and promotion to win over more parents and young women to the benefits of immunisation.

They are well aware that the natural scepticism of some parents may persist for some time to come. But the nurses believe that as more and more Year 8 girls are seen lining up for their vaccine – and the cervical cancer rates start to decline – that the new immunisation will come into its own.