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Human papillomavirus vaccination and cervical cancer screening by socioeconomic status, Victoria

TO THE EDITOR: From 2007 to 2009 in Australia, a three-dose course of quadrivalent human papillomavirus (HPV) vaccine was offered to all females aged 12–26 years through school and primary health care settings, with coverage recorded on the National HPV Vaccination Program Register (NHVPR). Women of lower socioeconomic status are at higher risk of cervical cancer in Australia.1 Inequities in cervical cancer screening have also been recognised by numerous studies nationally and internationally.1-3 If females in lower socioeconomic groups have lower participation in HPV vaccination, existing inequities in cervical cancer risk could widen. We analysed Victorian data on participation in HPV vaccination and cervical cancer screening (obtained from the NHVPR and the Victorian Cervical Cytology Registry) by socioeconomic status (based on Australian Bureau of Statistics 2006 Index of Relative Socio-economic Disadvantage for statistical local areas). From 1 July 2006 to 30 June 2008, participation in cervical screening was 58.7% in the most disadvantaged areas compared with 68.9% in the least disadvantaged areas (Box 1). A strong association was found between living in an area with higher average socioeconomic status and higher cervical screening rates in Victoria (P < 0.001). In contrast, HPV vaccination coverage from 2007 to 2009 showed a less pronounced socioeconomic gradient (Box 2). For the cohort of schoolgirls aged 12–17 years in 2007, three-dose coverage ranged from 73.1% in the most disadvantaged areas to 75.9% in the least disadvantaged areas (P < 0.001); for the cohort of women aged 18–26 years in 2007, coverage was 33.4% in the most disadvantaged areas and 38.0% in the least disadvantaged areas (P < 0.001). The National Cervical Screening Program is delivered mainly through primary health care services by general practitioners and nurses. The government-funded HPV vaccination program, delivered through schools, has contributed to a fairly equitable uptake across Victoria. Similar results have been found in the United Kingdom, which also has a schoolbased program,4 but not in the United States, where vaccination is not school based and universal government funding is not provided.5 Prevention of cervical cancer using school-based vaccination programs may result in more equitable cervical cancer prevention for females across the community than screening as currently accessed in Victoria. This ecological analysis should be supplemented by local monitoring of HPV vaccination coverage within and between schools at the area level, to ensure a reduction in inequities in cervical cancer incidence and mortality.