Low Coverage, Vaccine Hesitancy: Far Way to Go after HPV Vaccine Launched in Mainland China - Evidence from a Greater Bay Area Survey

Background: Human papillomavirus (HPV) vaccine was proved as one of the effective strategies in disease prevention and have been implemented successfully in most high-income countries. In 2018, WHO called for elimination action of cervical cancer as a public health problem and global action to scale-up vaccination. However, morbidity and mortality of cervical cancer in China showed in a rising trend in the past 3 decades. Bivalent, quadrivalent and nine-valent HPV vaccines were launched in China respectively until from July 2017 to the end of 2018, but lack of national coverage information. As the biggest developing country with largest population in low-income and middle-income countries (LMICs), HPV vaccination status and female's willing will be the nonnegligible factors considered in a global cervical cancer elimination strategy at the World Health Assembly to be held in May, 2020. In this survey, we aimed to assess the vaccination rate for all these three HPV vaccines and HPV screening rate in college students from Guangdong-Hong Kong-Macao Greater Bay Area (GBA) in China, to evaluate the influence factors for their vaccination and also reasons for their attitude. Methods: HPV vaccine vaccination records after HPV vaccine marked in China were collected from Guangzhou (biggest city in GBA) vaccination system. From October to December, 2018, we conducted a face to face questionnaire with students from 12 colleges in GBA university town. HPV vaccine vaccination and HPV screening behavior were self-reported by interviewee and vaccination was double checked in vaccination system via ID card number. Knowledge level and attitude were estimated by investigator. Vaccination related influence factors were estimated by logistic regression. Findings: Overall 3 dose HPV vaccine coverage from Oct. 2017- Mar. 2019 was extremely low: 0.73%, with bivalent vaccine of 0.25%, quadrivalent vaccine of 0.46% and nine-valent vaccine of 0.02%, respectively. 5414 college students participated, and 5307 valid questionnaires were collected. Overall, screening rate of cervical cancer was 11.82% (95%CI: 9.03%, 14.61%) and the coverage of HPV vaccine was pretty low in 3.09% (95%CI: 2.62%,3.56%), with “urban background” (4.62%, 95%CI: 3.82%, 5.42% VS 1.60%, 95%CI: 1.13%, 2.07%), along with increased monthly expense, highest in “≥2000 RMB/ month” group(7.75%, 95%CI: 5.97%, 9.53%), had a higher and significant coverage, and “sexual behavior” group (5.56%, 95%CI: 2.21%, 8.91) was high but not significant. 55.57% of participants were still hesitant and uncertain about vaccination. Uncertain about the long-effect of HPV vaccine was the biggest barrier for they vaccinating (62.75%), followed by high price (54.30%), unheard of HPV vaccines (53.45%), fear of side effects (51.99%) and disbelief in the effectiveness of vaccines (51.84%). Urban background (OR=2.131.36-3.33) ,higher monthly consumption (OR=2.59, 1.85-3.62), aware of vaccination adaptive population (OR=3.06, 1.88-4.99) and HPV infection high risk factors (OR=2.49, 1.08-5.74),and have a clear attitude towards vaccine protection effect, no matter yes (OR=11.88, 4.13-34.18) or no (OR=2.87, 1.30-6.30), were significantly influence factors for their vaccination. Interpretation: Low vaccination rate and vaccination hesitation are important obstacles in China to achieve cervical cancer elimination goals called from WHO. The reasons behind this are the lack of national policies and funding guarantees in the early stage after marketing, the insufficient experience for in-depth education interventions, and insufficient personal awareness. The introduction of HPV vaccines in mainland China is just the beginning, not the end. In the future, the Chinese government still has a long way to go to improve the vaccination rate of target people and strengthen the primary and secondary prevention measures in cervical cancer control and elimination.Funding Statement: The Project for Key Medicine Discipline Construction of Guangzhou Municipality (2013-2015-07).Declaration of Interests: All authors have nothing to disclose.Ethics Approval Statement: This Survey was approved by ethics commute of Guangzhou Center for Disease Control and Prevention. All participants provided informed consent before the questionnaire survey